A 37-year-old female G3P2 presents to your department in early labor at the 40th week of gestation. The cervix is 4 cm dilated, 40% effaced, anteriorly positioned, firm, and fetal station is at -3. The patient has a contraction every 5 minutes. She is given an epidural anesthesia with bupivacaine. After 3 hours, labor induction is considered. The cervix is ripened with dinoprostone and oxytocin infusion is given to augment contractions. The patient delivers a 4200g baby boy with APGAR score of 7 and 9 at 1 and 5 minutes, respectively. While awaiting placental removal, the patient has tachypnea with 35 respirations per minute, oxygen saturation drops to 78% and her BP is 85/40 mmHg. Immediate intubation is done and blood transfusion is started. 15 minutes later the bloody oozing is noted at IV sites.
Which of the following is the most likely diagnosis?
Correct Answer B:
This patient’s dramatic change of status with rapidly developing dyspnea and hypotension and possibly disseminated intravascular coagulation (manifested by oozing of blood at the IV site) after labor induction is suggestive of amniotic fluid embolism (choice B). It is a rare obstetric emergency with a pathophysiology that is still incompletely understood, but is potentially fatal and is characterized by dramatic development of hypoxia, hypotension or cardiac arrest, coagulopathy, during labor, Cesarean section, or within 30 minutes post-partum. Risk factors are meconium stained amniotic fluid, precipitous labor, oxytocin-stimulated labor, intrauterine pressure catheter insertion, male sex of the fetus, placental abruption, multiparity, advanced maternal age, uterine overdistention, fetal death, and trauma. Oxytocin stimulated labor has been associated with 50% of all amniotic fluid embolism cases.
→ Uterine atony (choice A) can result in prolonged bleeding and hemorrhage-induced hypotension. It can occur in oxytocin-stimulated labor and a large fetus is a risk factor; however, the respiratory and coagulopathy complications seen in this patient cannot be explained by uterine atony alone.
→ Superior vena cava embolism (choice C) is more common in patients with a permanent infusion catheter in the subclavian vein and superior vena cava. This patient’s clinical picture suggests amniotic fluid embolism.
→ Transfusion reaction (choice D) is incorrect. Dyspnea and hemodynamic instability occurred before transfusion was performed.
→ Epidural anesthesia complication (choice E) can certainly cause hypotension but bradypnea, not tachypnea, is more likely to occur, and the DIC seen in this patient is unlikely to be a side effect or complication anesthesia.
Key point:
A woman with regular menstrual cycle of 35 days duration is planning pregnancy. She asks you to advise her on the use of urinary LH kit in order to time intercourse so as to maximize her chances of getting pregnant.
Which of the followings days of the cycle is the best to start using the five sticks LH test?
Correct Answer C:
In this woman ovulation is expected to occur on day 21 of the cycle and she should thus start using the five stick urinary LH kit on day 18 (choice C) to pick the LH surge. The duration of luteal phase (from ovulation to next menstruation) of the ovarian cycle is relatively constant and is about 14 days in most women irrespective of the total duration of the cycle. In a woman with cycle of duration of 35 days, ovulation is expected to occur 14 days before the next menstruation (on day 21). LH surge usually starts 24 to 36 hours prior to ovulation, or days 20 or 19 of the cycle of our patient. A five stick test (one stick per day) started on day 18 would last till day 23 and is expected to detect the LH surge if it begins on any of these days.
→ If the five sticks urinary LH kit is started on day 11 (choice A) the LH surge might be missed. The last or fifth stick of the kit will be used on day 16 or well before the LH surge starts (day 18 or 19).
→ If the five sticks urinary LH kit is started on day 14 (choice B) the LH surge might still be missed. The last stick of the kit will be used on day 19 and the LH surge can be missed if it begins on day 20.
→ If the five sticks urinary LH kit is started on day 21 (choice D) the LH surge might show a high urinary LH level but might fail to show any change in the pattern of urinary LH secretion. One might not be sure of whether this high urinary LH level is part of LH surge.
→ If the five sticks urinary LH kit is started on day 24 (choice E) the LH surge might have already been dissipated had ovulation occurred on day 21.
A 29-year-old G2P0 female presents to your department because she has noted discharge, mucus and blood through her vagina the last 2 days. She is in the 21st week of gestation and her first pregnancy ended in preterm labor after 22 weeks of gestation 18 months ago. She denies contractions, cramping, and pain. On physical examination the patient’s cervix is 5 cm dilated and 80% effaced.
Which of the following is most likely to be the cause of preterm labor in this patient?
Correct Answer D:
This patient is presenting with preterm labor, which is labor that occurs after the 20th week of gestation and before the 37th week of gestation. Before the 20th week of gestation, pregnancy loss is called spontaneous abortion or miscarriage. Common causes of pregnancy loss differ depending on the timing during the course of gestation they occur. The well known most common cause of pregnancy loss in the first trimester is chromosomal abnormalities but they only cause few pregnancy losses in second trimester pregnancies. The most common cause of pregnancy loss in the second trimester is cervical insufficiency (choice D). Cervical dilation and effacement without contractions or pain in a pregnant woman who is in the 2nd trimester or gestation suggests this diagnosis. Cervical insufficiency is often due to a history of cervical trauma such as repeated therapeutic abortion, repetitive cervical dilatation, cone biopsy, cervical tears and lacerations, and trachelectomy. Other causes of cervical insufficiency include congenital structural uterine abnormalities and collagen abnormalities such as those seen in Ehlers-Danlos syndrome because hyperextensibility results in the fragility of the cervix as the pregnancy progresses and leads to premature deliveries.
→ Systemic lupus erythematosus (choice A) is associated with antiphospholipid antibodies and the development of placental thrombosis and is a well-established risk of second and third trimester pregnancy loss. It is often associated with pain, cramping, and clots formations.
→ Fetal chromosomal abnormalities (choice B) is much more common cause of pregnancy loss in the first trimester.
→ Placenta previa (choice C) is a leading cause of third trimester hemorrhage and classically presents with painless vaginal bleeding. It is also associated with increased risks of premature delivery in the third trimester but is less common than cervical insufficiency in the second trimester. Placenta previa patients who go on to have preterm labor are more likely to have uterine contractions.
→ Human papilloma virus infection (choice E) is a cause of genital warts, cervical dysplasia, and cervical cancer. While cervical dysplasia that requires cervical conization could result in cervical insufficiency and increased risks of preterm labor, HPV infection in itself without any other complication is not currently known to be associated with higher risks of second trimester preterm labor.
A 30-year-old female presents to your clinic for a follow-up. She recently did a pelvic ultrasound that revealed a 4 cm right-sided ovarian cyst. The patient is asymptomatic.
What is the most appropriate next step in management?
Correct Answer E:
This patient is a young woman with an ovarian cyst that is asymptomatic and is less than 5 cm in size. The management of ovarian cysts depends on the age of the patient, the size of the cyst, and the symptoms. Many patients with simple ovarian cysts based on ultrasonographic findings do not require treatment. In a postmenopausal patient, a persistent simple cyst smaller than 5cm in dimension in the presence of a normal CA125 value may be monitored with serial ultrasonographic examinations. In a 30-year-old patient, like this woman, if the cyst is smaller than 5 cm in diameter, a repeat ultrasound can be done in 8-12 weeks (choice E) and oral contraceptive pills are used to prevent further development of new cysts though they are not useful in resolving pre-existing cysts.
→ Ovarian biopsy (choice A) is an invasive procedure that is unnecessary in an otherwise healthy premenopausal female with a cyst < 5 cm in size.
→ Next month re-evaluation (choice B) is incorrect. Re-evaluation with repeat ultrasound is recommended in 2-3 months. 70% of cysts regress on their own in 6 weeks to several months.
→ Laparoscopy (choice C) is recommended for cysts 5 cm - 10 cm that are symptomatic.
→ Order cancer antigen-125 (choice D) should be ordered in a post-menopausal patient, but is not recommended in a premenopausal young woman with a < 5cm cyst, which is likely to be a functional cyst.
A 27-year-old female G2P1 presents to your department for prenatal check up at the 28th week of gestation. Her blood pressure is repeatedly measured and found to be 155/100 mmHg. She has no history of diabetes or hypertension. Physical examination reveals pedal edema. Urine sample evaluation is negative for protein.
Which of the following is the most appropriate treatment?
This patient’s condition is most likely to be gestational hypertension, which is blood pressure higher than 140/90 mmHg measured on two separate occasions, more than 6 hours apart, without the presence of protein in the urine and diagnosed after 20 weeks of gestation. This is followed by normalization of the blood pressure postpartum, though it can be a precursor of hypertension later in life. Gestational hypertension is normally treated with alpha methyldopa (choice B).
→ Hydrochlorothiazide (choice A), Spironolactone (choice E), and other diuretics are usually avoided in pregnancy as they prevent the physiologic volume expansion seen in normal pregnancy.
→ Lisinopril (choice C) and other angiotensin-converting enzyme inhibitors should be avoided during pregnancy, as they are associated with fetal renal dysgenesis or death when used in the second and third trimesters, as well as with increased risk of cardiovascular and central nervous system malformations when used in the first trimester.
→ Diltiazem (choice D) is a category C drug. While it has not been extensively studied in humans, it appears to cause harmful effects in animal studies and would not be the best choice for this patient.
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