A 65-year-old woman comes to your office for routine well-woman exam. Her last menstrual period was 15 years ago. She has not been on estrogen replacement therapy and now desires to start due to concerns about osteoporosis. On routine pelvic exam, you palpate a small uterus and cervix along with palpable ovaries bilaterally.
Of the following, your next step in the management of this patient should be:
Correct Answer C:
In a postmenopausal woman, the ovaries should not be palpable; if they are, it should raise the concern that an ovarian malignancy is present. Before one would perform an operative evaluation, radiologic assessment should be done.
A. Although this is an accepted regimen for estrogen replacement therapy, the palpable ovaries need to be evaluated to rule out malignancy.
D. Dual photon densitometry will give a reliable measure of bone density. Again, however, the palpable ovary is the first thing that needs to be worked up.
E. Although surgical exploration may be warranted, initial workup of the adnexal mass should include an ultrasound along with tumor markers. A CT scan may also be warranted.
All of the following are contraindications to epidural anesthesia, except:
Correct Answer E:
Contraindications for epidural anesthesia include: patient refusal for surgery, uncooperative patients. abnormal bleeding or clotting parameters, anti-coagulant therapy, skin infection at/near injection site, uncorrected fluid loss (hypovolemia), low blood pressure, presence of neurological disorders, cardiovascular disease, anatomical abnormalities of the vertebral column.
It is indicated in difficult or high-risk labour, twin pregnancy, pre-eclampsia, prolonged labor.
Which one of the following is associated with the use of epidural anesthesia during labor and delivery?
Correct Answer B: Studies have shown that epidural analgesia increases the length of both the first and second stage of labor. Although there is an increase in the rate of instrument-assisted delivery and fourth degree laceration, an increase in the rate of cesarean sections has not been shown. An increase in the rate of urinary incontinence also has not been shown.
Compared to anesthesia using only parenteral opioids, the use of epidural anesthesia in labor and delivery increases the rate of which one of the following?
Correct Answer D:
Multiple systemic reviews have been conducted to examine effects of epidural anesthesia on maternal and neonatal outcomes. There are many confounding variables in the studies and, as a result, only a few effects of epidural anesthesia are consistently seen on a statistically significant basis: an increased duration of the second stage of labor, an increased rate of instrument-assisted vaginal deliveries, and an increased likelihood of maternal fever. Overall, there is no statistically significant difference in the duration of the first stage of labor, the incidence of low Apgar scores, or the incidence of maternal backache at 3 months or 12 months.
A pregnant woman has a placental abruption. She then develops ecchymosis and bleeding. You strongly suspect disseminated intravascular coagulation (DIC).
What is the most specific test to confirm this?
Correct Answer A:
Disseminated intravascular coagulation (DIC) involves abnormal, excessive generation of thrombin and fibrin in the circulating blood. During the process, increased platelet aggregation and coagulation factor consumption occur. DIC that evolves slowly (over weeks or months) causes primarily venous thrombotic and embolic manifestations; DIC that evolves rapidly (over hours or days) causes primarily bleeding.
Severe, rapidly evolving DIC is diagnosed by demonstrating thrombocytopenia, an elevated PTT and PT, increased levels of serum fibrin degradation products, and a decreasing plasma fibrinogen level.
Treatment includes correction of the underlying cause and replacement of platelets, coagulation factors (in fresh frozen plasma), and fibrinogen (in cryoprecipitate) to control severe bleeding. Heparin is used as therapy (or prophylaxis) in patients with slowly evolving DIC who have (or are at risk for) venous thromboembolism.
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