A primigravid at term presents in labor. Her pregnancy is complicated by the fact that she has a twin gestation.
The most common presentation of these twins at delivery is:
Correct Answer C:
The most common presentation of twins at delivery is vertex/vertex followed next by vertex/breech.
A. Least common presentation.
B. Less common presentation.
D. Second most common presentation.
E. Third most common presentation.
A G5P5 post-delivery develops a postpartum hemorrhage.
What is the most likely cause?
This patient having five deliveries most likely has uterine atony.
Postpartum hemorrhage commonly results from bleeding at the placental implantation site. Risk factors for bleeding at this site include:
Other possible causes of hemorrhage - lacerations of the genital tract, extension of an episiotomy, or uterine rupture - must also be considered. Uterine fibroids may contribute. Postpartum hemorrhage due to subinvolution (incomplete involution) of the placental site usually occurs early but may occur as late as 1 month after delivery.
A 37-year-old gravida 6 para 5 is given oxytocin (Pitocin) to induce delivery at 41 weeks gestation. Her prenatal course is significant for chronic hypertension. She delivers a 4020-g (8 lb 14 oz) baby. Soon after delivery of the placenta, she begins to have excessive vaginal bleeding.
Which one of the following would you do initially?
Correct Answer A:
The incidence of postpartum hemorrhage is 5%-8%. Causes include uterine atony, lacerations, retained placental products, and defects of coagulation. Uterine atony is the most likely cause of hemorrhage in this patient with multiple risk factors, including grand multiparity, a large fetus (uterine distension), and oxytocin induction. The initial step in management of postpartum hemorrhage should be manual uterine exploration followed by bimanual massage and compression of the uterus. This maneuver may need to be performed for upwards of 30 minutes. Intravenous oxytocin should also be infused simultaneously.
→ Uterine curettage (choice B) may be performed to attempt to remove retained placental products. However, it carries a significant risk of uterine perforation and should be delayed unless bleeding cannot be controlled by other means.
→ Methergine (choice C) is useful for postpartum hemorrhage but is contraindicated in this patient with hypertension.
→ Terbutaline (choice D) is a tocolytic and is not used for treatment of hemorrhage.
→ Prostaglandin F2alpha (choice E) is an effective treatment for postpartum hemorrhage, but should be reserved for use when uterine massage fails.
In order to stop intractable uterine bleeding from postpartum hemorrhage, ligation of the internal iliac arteries is performed.
Blood flow will be greatly diminished in all of the following arteries, except:
Correct Answer E:
The internal iliac branches into an anterior and a posterior division. The posterior division gives rise to the superior gluteal (choice B), iliolumbar, and lateral sacral. The anterior division gives off the obturator (choice A), internal pudendal, uterine, superior and inferior vesical (choice D), vaginal branches, and the obliterated umbilical artery. The middle and inferior rectal (choice C) arteries arise off of the internal pudendal. The external pudendal arises off of the external iliac at the level of the inguinal ligament (along with the deep inferior epigastric and circumflex iliac, and sometimes the aberrant obturator).
The superior rectal (choice E) is the final branch of the inferior mesenteric.
A woman develops swelling in her labia minora. The area is painful and red. See illustration:
What is the most likely diagnosis?
Correct Answer B:
Bartholin's gland cysts are mucus-filled and occur on either side of the vaginal opening. They are the most common large vulvar cysts. Bartholin's cysts may form an abscess, which are painful and usually red.
Most cysts are asymptomatic, but large cysts can be irritating, interfering with intercourse and walking. Most cysts are nontender, unilateral, and palpable near the vaginal orifice.
Diagnosis is usually by physical examination. In women < 40, asymptomatic cysts do not require treatment. Symptomatic cysts may require surgery. Because cysts often recur after simple drainage, surgery aims to produce a permanent opening from the duct to the exterior. A small balloon-tipped catheter (called a ‘word’ catheter) may be inserted, inflated, and left in the cyst for 4 to 6 weeks.
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