In a differential diagnosis of third trimester bleed, which of the following should not be included?
Correct Answer D: Causes of bleeding during the third trimester include placenta previa (20%), placental abruption (30%), ruptured vasa previa, uterine scar disruption and bloody show.
Threatened abortion is vaginal bleeding occurring before the 20th week of pregnancy and indicating that spontaneous abortion may occur.
A 26-year-old white female presents to you 5 weeks after her last menstrual period with complaint of painless spotting for 2 days. She has not been using contraception and is trying to conceive. She had regular menses until her last menstrual period, and a home pregnancy test was positive 5 days ago. Her only previous pregnancy, 4 years ago, was electively terminated at 8 weeks gestation. Her past history is significant for an episode of presumed salpingitis treated with intravenous antibiotics 2 years ago.
Physical Findings:
Laboratory Findings:
The most appropriate action at this point is to:
Correct Answer D: In a pregnancy complicated by bleeding at less than 8 weeks gestation, it is often difficult to determine whether there is a viable intrauterine pregnancy, a nonviable intrauterine pregnancy, or an ectopic pregnancy.
Vaginal ultrasonography can be used to detect intrauterine pregnancy as early as 1 week after conception if the beta hCG level is > 1500 mIU/mL. An empty uterus with a beta-hCG level > 1500 mIU/mL is highly suggestive of ectopic pregnancy. When the beta-hCG is < 1500 mIU/mL and vaginal ultrasonography is nondiagnostic, the beta-hCG should be repeated in 2-3 days (choice D). Failure of the beta-hCG to double in 2-3 days suggests a blighted ovum or ectopic pregnancy. The efficacy of progesterone in early pregnancy has not been proven, and there is some potential risk (virilization of the female fetus). An ectopic pregnancy is possible in this situation, but would be more like if the hCG were higher in the presence of an empty uterus, or if there were an adnexal mass on physical examination or ultrasonography.
A 37-year-old gravida 3 para 2 at 33 weeks gestation reports the onset of brisk vaginal bleeding. On examination the uterus is nontender and 32 cm above the symphysis. Pelvic examination reveals the presence of a large amount of bright red vaginal blood.
This presentation is most consistent with:
Correct Answer C:
The classical clinical presentation of placenta previa is painless, bright red vaginal bleeding. This diagnosis must be considered in all patients beyond 24 weeks gestation who present with bleeding. Threatened abortion is unlikely at this stage of pregnancy and hemorrhagic cystitis is not accompanied by brisk bleeding. Abruption of the placenta is the most common cause of intrapartum fetal death but is associated not only with brisk vaginal bleeding, but also with uterine tenderness that may be marked. Clinical signs of chorioamnionitis include purulent vaginal discharge, fever, tachycardia, and uterine tenderness.
Which one of the following vaccines is contraindicated in pregnancy?
Correct Answer E:
Although the risk of transmitting a virus to a developing fetus is primarily theoretic, live-virus vaccines are generally contraindicated in pregnancy. MMR is a live attenuated vaccine and thus should be avoided in pregnancy. If it is inadvertently given, or a woman becomes pregnant within 4 weeks of administration, the woman should be counseled regarding potential adverse effects on the fetus, but should not be advised that it is an indication for termination.
Tetanus and diphtheria vaccine (Td) should be routinely recommended for pregnant women who have not received Td in the past 10 years, or who have never been immunized. The influenza vaccine is a killed-virus preparation and is recommended for all women who will be pregnant during the influenza season.
Rabies vaccination has not been associated with any fetal abnormalities. Due to the potential severe consequences of rabies exposure to the mother and fetus, the guidelines for postexposure prophylaxis in pregnancy are similar to those for the nonpregnant patient. Hepatitis B vaccine is composed of a viral surface antigen made through recombinant DNA technology and poses no risk to the mother or fetus. It should be routinely recommended to women who have risk factors including multiple sexual partners, a history of intravenous drug use or a partner with a history of intravenous drug use, occupational exposure, or household contact with a chronic carrier or acutely infected person.
A 23-year-old female is at 8 weeks gestation with her first pregnancy. She is planning to travel to Third World countries soon for job-related reasons.
Which one of the following is contraindicated in this patient?
Immunizations that are safe during pregnancy include tetanus and diphtheria toxoids (Td), hepatitis B vaccine, influenza vaccine, meningococcal vaccine, and rabies vaccine. Those that are contraindicated, or whose safety has not yet been established, include mumps, measles, rubella, and varicella vaccines.
Vaccines to which special recommendations pertain include anthrax, hepatitis A, Japanese encephalitis, pneumococcal, polio (IPV), typhoid, vaccinia, and yellow fever vaccines. In the case of hepatitis A, the vaccine is produced from an inactivated virus and risk to the developing fetus is low. The risk of vaccination should be weighed against the risk of exposure to hepatitis A.
Click to expand