A 39-year-old pregnant woman with chronic hypertension and one prior pregnancy is now at 38 weeks' gestation. She comes to labor and delivery with profuse vaginal bleeding and abdominal pain of sudden onset.Which of the following is the most likely diagnosis?
Answer(s): E
Painful vaginal bleeding is most likely the result of placental abruption, premature separation of the placenta. Bloody show is a normal sign of impending or early labor. The bleeding is scant and intermingled with clear mucus. Bleeding from a vaginal laceration following coitus is not associated with abdominal pain.A history of coitus followed immediately by bleeding suggests this diagnosis. Bleeding from cervicitis is most often spotting and not associated with abdominal pain. Classically, bleeding with a placenta previa is painless.
A 39-year-old pregnant woman with chronic hypertension and one prior pregnancy is now at 38 weeks' gestation. She comes to labor and delivery with profuse vaginal bleeding and abdominal pain of sudden onset.If the patient has a placental abruption, which of the following is the most likely risk factor
Answer(s): D
Maternal hypertension is the most common risk factor for a placental abruption. The relative risk is 3.8 for parous women and 1.6 for nulliparous women. In one published report, half of the women with an abruption severe enough to kill the fetus had hypertension, and half of these had evidence of chronic vascular disease. Advanced maternal age without confounding factors such as diabetes or hypertension is not a risk factor for placental abruption. High parity is associated with an increased risk of placental abruption.Vigorous coitus can cause a vaginal laceration, but not abdominal pain. While blunt abdominal trauma may cause a placental abruption, routine forms of exercise are not a risk factor for placental abruption.
A 39-year-old pregnant woman with chronic hypertension and one prior pregnancy is now at 38 weeks' gestation. She comes to labor and delivery with profuse vaginal bleeding and abdominal pain of sudden onset.This patient has an external fetal monitor placed. Uterine tone seems to be increased, and there are occasional variable decelerations of the fetal heart to 90 BPM. Which of the following is the most appropriate management?
At term, a placental abruption severe enough to cause fetal distress warrants immediate delivery. If the pregnancy is remote from term, temporizing measures may be considered, such as observation. However, delivery should be achieved if the mother becomes hemodynamically unstable. Tocolysis is ineffective in relaxing the uterus and has the added disadvantage of causing vasodilation of an already under-filled vascular system. Amniotomy and Pitocin induction will not cause delivery rapidly enough to prevent further deterioration of the fetus. Evidence of fetal distress makes continued monitoring unacceptable.
A pediatrician asks you to see a 13-year-old girl who has not begun to menstruate and has a 6-month history of pelvic and lower abdominal pain at approximately 1-month interval. She has Tanner stage 3 pubic hair and breast development. Her growth spurt occurred about 1 year ago and her current height is 65 in. (165 cm). She has never had sexual intercourse. On examination of her external genitalia the presence of Tanner stage 3 pubic hair is confirmed. The labia are normal. There is no obvious vaginal opening and there is bulging between the labia minora.Which one of the following is the most likely diagnosis?
The presence of pubertal events except external menstruation and the bulging of the hymen causing retrograde menstruation as a cause of her cyclic pain establish the diagnosis of imperforate hymen.Strictly, these women have cryptomenorrhea, not amenorrhea. Women with mittelschmerz (ovulation pain) menstruate cyclically. While pubertal events except menstruation occur normally in women with Müllerian/ vaginal agenesis, cyclic pain is absent because the uterus is hypoplastic or absent and there is no endometrium to shed. Women with gonadal dysgenesis do not develop breasts or pubic hair and have primary amenorrhea. The most common form of gonadal dysgenesis is 45,X Turner syndrome and affected females are less than 62 in. tall.
A pediatrician asks you to see a 13-year-old girl who has not begun to menstruate and has a 6-month history of pelvic and lower abdominal pain at approximately 1-month interval. She has Tanner stage 3 pubic hair and breast development. Her growth spurt occurred about 1 year ago and her current height is 65 in. (165 cm). She has never had sexual intercourse. On examination of her external genitalia the presence of Tanner stage 3 pubic hair is confirmed. The labia are normal. There is no obvious vaginal opening and there is bulging between the labia minora.Which one of the following laboratory tests is increased in women with gonadal dysgenesis?
Answer(s): A
Women with gonadal dysgenesis have fibrous streaks instead of functioning gonads. As a result secretion of estradiol and testosterone is decreased. Serum FSH concentrations are increased because of the lack of negative feedback to the hypothalamus and pituitary as a result of diminished sex steroid secretion by the streak gonads. Other pituitary hormones, such as TSH and prolactin are not regulated by sex steroids and their concentrations are normal.
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