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since I was in med school this subject has always got on my nerves and I have just passed in it...
I am starting this thread to discuss the u world questions which will be helpful for others too..
Q id 2535
A 28-year-old woman. gravida 3. para 2. at 35 weeks gestation is rushed to the emergency department
because of vaginal bleeding. She was sleeping when she first noticed the bleeding. She has had no uterine
contractions. Her prenatal course. prenatal tests and fetal growth have been normal. Prenatal ultrasound at
the 14th week of gestation showed an intrauterine gestation consistent with dates and showed no
abnormalities. Her previous pregnancies were uncomplicated. Her temperature is 37 .DC (98. 7F). blood
pressure is 90/60 mmHg. pulse is 116/min and respirations are 16/min. Physical examination shows cold
extremities and bright red vaginal bleeding. Which of the following is the most appropriate next step in
management?
r A. Emergency transvaginal ultrasonogram
r B. Obtain blood for PT/INR and PTT
r C. Obtain venous access with two large bore needles
r D.lmmediate vaginal examination
r E. Immediate cesarean section
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Explanation:
The patient presents with a severe antepartum hemorrhage that has caused hypotension. tachycardia and
physical signs of poor peripheral perfusion. She is at risk of developing hypovolemic shock. Hemodynamic
resuscitation must be promptly initiated before starting any measure to diagnose the source of blood loss.
The most common causes of antepartum hemorrhage are placenta previa and abruptio placenta.
(Choice A) Emergency ultrasound is an essential step in diagnosing the cause of antepartum bleeding as
pelvic examination carries the risk of exacerbating the bleeding before placenta previa is ruled out. but
hemodynamic resuscitation must be performed first.
(Choice B) Coagulation disorders are seldom responsible for antepartum hemorrhage. but an assessment of
the patient's coagulation profile is necessary in such a situation after emergent fluid resuscitation has been
accomplished.
(Choice D) Vaginal examination is contraindicated in the case of antepartum hemorrhage because it can
aggravate the bleeding from placenta previa. It can be safely done following an ultrasonogram that excludes
placenta previa.
(Choice E) Cesarean section may be needed if the patient continues to be unstable; however. hemodynamic
stability should be attained first.
Educational objective:
Maintenance of airway. breathing and circulation is always the first priority in any patient presenting for
emergent care. Hemodynamic resuscitation must be promptly initiated before starting any measure to
diagnose the source of blood loss in patients with antepartum hemorrhage who are hemodynamically
unstable.
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The following vignette applies to the next 3 items. The items in the set must be answered in sequential
order. Once you click Proceed to Next Item. you will not be able to add or change an answer.
A 24-year-old woman delivered a healthy baby by vaginal delivery at 36 weeks gestation. She had a prolonged
premature rupture of the membranes. and mid forceps application was required during delivery. On the
second postpartum day she complained of fever and chills. She cannot breast-feed because her "nipples are
tender". Her temperature is 38 .5C ( 1 01 .3F). blood pressure is 120/55 mmHg and pulse is 92/min. Bimanual
examination shows tender uterus and foul-smelling lochia. Her nipples are cracked but without surrounding
erythema or warmth. Physical examination otherwise shows no abnormalities.
Item 1 of3
Which of the following is the most likely diagnosis?
r A. Normal postpartum
r B. Puerperal mastitis
r C. Endometritis
r D. Deep venous thrombosis
r E. Aspiration pneumonia
ltem2 of3
Which of the following pathogens is most likely responsible for this patient's current condition?
r A. Chlamydia lrachomalis
r B. Group B Streptococcus
r C. Neisseria gonorrhea
r D. Staphylococcus aureus
r E. Polymicrobial infection
ltem3 of3
Which of the following is the most appropriate initial therapy for this patient?
r A. Vancomycin and gentamicin
r B. Clindamycin and metronidazole
r C. Vancomycin and clindamycin
r D. Clindamycin and gentamicin
r E. Ceftriaxone and azithromycin
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Qid 4799
Explanation:
The patient described is experiencing postpartum endometritis. A puerperal infection should be suspected if a
woman experiences a fever greater than 38 C ( 1 DO .4 F) outside of the first 24 hours postpartum. Risk factors for endometritis include. but are not limited to prolonged rupture of the membranes(> 24 hours). prolonged labor(> 12 hours). cesarean section and use of intrauterine pressure catheters or fetal scalp electrodes. This patient has at least two of these risk factors. Clinically. endometritis is characterized by fever. uterine tenderness. foul smelling lochia and leukocytosis. Broad spectrum antibiotics are required to treat this typically polymicrobial infection.
(Choice A) While the normal postpartum period is associated with persistent vaginal discharge (lochia). this
discharge should steadily resolve over the first two weeks and should never be foul-smelling.
(Choice B) Puerperal mastitis occurs in breastfeeding mothers and can begin with a sore or fissured nipple.
but this diagnosis would be unlikely this soon after delivery.
(Choices D & E) Deep venous thrombosis and aspiration pneumonia would be associated with physical
examination findings consistent with each of these diagnoses. The physical examination in this patient is
normal other than the abnormalities such as uterine tenderness and foul-smelling lochia that indicate a
puerperal infection rather than one of these conditions.
Educational objective:
Endometritis is characterized clinically by fever and uterine tenderness in the postpartum period and is often
associated with foul-smelling lochia. Risk factors include prolonged ROM. prolonged labor. operative vaginal
delivery and caesarian section among others.
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Qid 4800
Explanation:
This patient has postpartum endometritis. Endometritis is the most common cause of puerperal fever on the
2nd and 3rd day postpartum. Endometritis is a polymicrobial infection caused by a combination of gram
positive and gram negative organisms. aerobic and anaerobic organisms and occasionally other organisms
such as Mycoplasma and Chlamydia.
(Choice A) Chlamydia lrachomalis is a common cause of pelvic inflammatory disease in nonpregnant
women. and can uncommonly cause postpartum endometritis. Postpartum endometritis due to Chlamydia
often occurs many days following delivery. not in the lirst 48- 72 hours.
(Choice B) Group B Streptococcus is a potential cause of both postpartum endometritis and neonatal
sepsis. Women are often screened for this organism and treated if colonized before delivery. Despite this
screening. GBS can be isolated along with other organisms in approximately one-third of cases of postpartum
endometritis.
(Choice C) Neisseria gonorrhea is one gram-negative organism that can be associated with postpartum
endometritis. It occurs in less than 1 0% of cases.
(Choice D) Staphylococcus aureus is not commonly isolated in cultures from women with
endometritis. Staphylococcus epidermidis. however. can often be recovered as part of a polymicrobial
infection in such women.
Educational objective:
Postpartum endometritis is most commonly a polymicrobial infection composed of gram positive and gram
negative organisms. aerobic and anaerobic organisms and occasionally other organisms.
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qid 4801
explanation:
Endometritis is a polymicrobial infection caused by a combination of gram positive and gram negative
organisms. aerobic and anaerobic organisms and occasionally other organisms such as Mycoplasma and
Chlamydia. Commonly isolated organisms include group B streptococci. group D streptococci.
Staphylococcus epidermidis. Escherichia coli. Neisseria gonorrhoeae. Gardnerella vagina/is. Bacteroides
fragilis. peptostreptococci and peptococci. Given the polymicrobial nature of postpartum endometrial
infections. the most appropriate therapy is intravenous clindamycin combined with an intravenous
aminoglycoside such as gentamicin.
(Choice A) Vancomycin is only effective against gram-positive organisms and gentamicin provides excellent
gram-negative coverage. but this regimen would not be as effective against anaerobic organisms.
(Choice B) Clindamycin and metronidazole are both active against anaerobic organisms but would not be
effective in eliminating gram-negative aerobic organisms.
(Choice C) Vancomycin and clindamycin would not provide adequate coverage of gram-negative aerobic
organisms.
(Choice E) Ceftriaxone and azithromycin is the treatment of choice for pelvic inflammatory disease. The
cephalosporin treats N. gonorrhoeae while the macrolide treats C. trachomatis.
Educational objective:
The treatment of choice for postpartum endometritis. which is a polymicrobial infection. is intravenous
clindamycin and gentamicin.
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from mtb 2
Anaerobes
Oral (above the diaphragm)
• Penicillin (G, VK, ampicillin, amoxicillin)
• Clindamycin
Abdominal/gastrointestinal
• Metronidazole, beta-lactam/lactamase combinations
Gram-Negative Bacilli (E. coli, Klebsiella, Proteus, Pseudomonas,
Enterobacter, Citrobacter)
These organisms cause infections of the bowel (peritonitis, diverticulitis); urinary
tract (pyelonephritis); and liver (cholecystitis, cholangitis).
All of these agents cover gram-negative bacilli:
• Quinolones
• Aminoglycosides
• Carbapenems
• Piperacillin, ticarcillin
• Aztreonam
• Cephalosporins
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q id 4758
A 23-year-old G 1 PO female presents for her first prenatal visit at 14 weeks gestation. A pap smear is done at
that time and a high grade squamous intraepitheliallesions (HSIL) is seen at cytology. A test for HPV
discloses the presence of a strain with high oncogenic risk. A satisfactory colposcopy is done and shows no
site of abnormalities. At this time the next best step is:
r A. Loop electrosurgical excision procedure (LEEP)
r B. Repeat pap smear 12 months
r C. Termination of pregnancy
r D. Repeat colposcopy and biopsy after delivery
r E. Endocervical curettage
