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368. The answer is C. (Chapter 101) The etiologies of SAB can be divided into two categories: fetal and maternal. Fetal chromosomal abnormalities are the major cause of SAB. Maternal factors include uterine anomalies, incompetent cervix, progestin deficiency, and chronic medical problems such as diabetes mellitus and thyroid disease. Although the majority of spontaneous abortions occur before the 8th or 9 th week of gestation, they can occur up to the 20th week. The incidence of SAB rises with increased maternal and paternal age and with parity. Pain associated with abortion usually follows the commencement of vaginal bleeding and is typically midline and crampy. This is in contrast to ectopic pregnancy or ruptured cyst in which pain is typically acute, severe, and unilateral.

369-370. The answers are D and B, respectively. (Chapters 98, 100) Because of the life-threatening potential of ectopic pregnancy, it is critical to determine whether a woman with pelvic pain is pregnant. A qualitative test for the p subunit of human chorionic gonadotropin (phCG) can be performed immediately at the bedside and thus is the first test indicated for any female patient of child-bearing age who is complaining of abdominal pain.

Ectopic pregnancy must be considered in every woman of child-bearing age who comes to the ED complaining of pain, even if she denies pregnancy. Ovarian torsion is uncommon, but when it occurs it causes unilateral pelvic pain. Endometriosis should be considered in any woman of reproductive age complaining of one or a combination of the following signs and symptoms: acute adnexal pain, premenstrual pelvic pain, worsening dysmenorrhea, and dyspareunia. Appendicitis is always in the differential of right lower quadrant pain. The key to the diagnosis of Mittelschmerz or "middle pain" is the fact that it occurs in mid-cycle, thus making it unlikely in this patient. A history of similar pain with each menstrual cycle may be elicited.

371. The answer is C. (Chapter 101) The possibility of ectopic pregnancy must be considered in every patient who presents with abnormal uterine bleeding or pelvic pain. A focused bedside ultrasound is consistent with ectopic pregnancy if there is no identifiable gestational sac or intrauterine pregnancy visualized. Less commonly, an adnexal mass may be present, but the mass does not always represent an ectopic pregnancy. Rhesus (Rh) status should be assessed. Rh-negative women with antepartum bleeding must receive RhoGAM to prevent antibody formation that would endanger future pregnancies. Serial phCG levels may be indicated in hemodynamically stable patients and should double in 48 h in a normal pregnancy. Urinalysis should be performed on patients with threatened abortion to rule out infection as a precipitant.

372. The answer is A. (Chapter 100) With the advent of bedside ultrasound, the use of cul-docentesis has decreased. However, this simple test still has a role in the pregnant patient with signs and symptoms of ectopic pregnancy when ultrasound is not available. A needle is inserted into the cul de sac just inferior to the cervix. A culdocentesis is positive if non-clotting blood is obtained and negative if clear fluid is aspirated. Failure to aspirate blood is nondiagnostic and may represent technical problems. Culdocentesis is positive in the majority of patients with ectopic pregnancies, ruptured and unruptured (85 and 65 percent, respectively). A positive test is not specific for ectopic pregnancy but occurs with any process that produces blood in the pelvis.

373. The answer is E. (Chapter 105) PID occurs in women from all socioeconomic backgrounds. Risk factors for the development of PID include a history of gonococcal infection, sexual promiscuity, adolescence, and IUD use. Instrumentation of the uterus and tubes may predispose patients to the development of endometritis and salpingitis.

374. The answer is A. (Chapter 105) The Centers for Disease Control and Prevention publishes guidelines delineating several appropriate treatments for PID. The presence of penicillinase-producing gonorrhea dictates a careful choice of antibiotics. If ceftriaxone is used to treat outpatient PID, the dose is 250 mg intramuscularly as opposed to the dose of 125 mg intramuscularly for simple cervicitis.

375. The answer is E. (Chapter 104) The most common causes of vulvovaginitis include (1) infections with Gardnerella, Candida albicans, Trichomonas, and herpes simplex; (2) contact vulvovaginitis; (3) foreign bodies; and (4) atrophic vaginitis. Bacterial vaginosis is the most common form, followed by candidiasis. Whereas 80 percent of patients with Trichomonas vaginalis have diffuse erythema of the vaginal vault, only 2 percent present with a "strawberry cervix" (secondary to diffuse punctate hemorrhages). Normal acidic vaginal secretions help to limit infection. In older women, because of scant nerve endings in the vagina, symptoms of vulvovaginitis do not present until advanced disease is present. Young children may present with vaginal itching and irritation secondary to pinworms.

376. The answer is A. (Chapter 99) All organ systems are affected by the physiologic changes of pregnancy. Although tidal volume is increased and functional residual capacity is decreased, respiratory rate and vital capacity remain unchanged. The other changes listed are all seen with normal pregnancy.

377. The answer is D. (Chapters 99, 102) Erythromycin base is safe to use in pregnancy, but erythromycin estolate should not be used because of drug-related hepatotoxicity. Other antibiotics considered safe in pregnancy include cephalosporins, nitrofurantoin, penicillin, and azithromycin. Heparin and insulin are large molecules that do not cross the placenta and are therefore safe in pregnancy.

378. The answer is B. (Chapters 99, 102) The most recent evidence suggests that 10 rad is the threshold for human teratogenesis and that the fetus is most vulnerable at 8 to 15 weeks of gestation. The position of the American College of Radiology is that there is no single test that results in radiation doses that threaten the well-being of the developing embryo or fetus. Radiation exposure is as follows: two-view chest radiograph with abdominal shielding, 0.00005 rad; head CT, < 0.1 rad; lumbrosacral spine series, 0.168 to 0.359 rad; IVP, 0.686 to 1.398 rad; and abdominal CT, 5.0 rad.

379. The answer is D. (Chapter 101) Etiologies of third-trimester abdominal pain include placental abruption, labor contractions, hypertension with hemolysis, elevated liver enzyme and low platelet (HELLP) syndrome, appendicitis, and rarely placenta previa from uterine irritation. Classically, placental abruption presents with vaginal bleeding; however, when the separation is central, bleeding is concealed. Ultrasound does not detect all abruptions. A speculum examination is safe and appropriate in the management of this patient. Digital examinations are contraindicated when the diagnosis of placenta previa is being considered. Immediate delivery is indicated if the patient is eclamptic or the fetus is in danger for another reason. CBC, electrolytes, BUN, creatinine, LFTs, and a urinalysis may help detect an infection, HELLP syndrome, or hemorrhage.

380. The answer is D. (Chapter 101) Preeclampsia (pregnancy-induced hypertension) occurs in about 7 percent of all pregnancies. It can present with a wide variety of symptoms. The classic triad is hypertension, proteinuria, and edema. The HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome represents an unusual presentation of this disease. Magnesium sulfate is indicated for seizure prophylaxis in patients with severe preeclampsia. Calcium gluconate is the antidote for magnesium toxicity. Obstetrical management is based on the degree of preeclampsia and the gestational age of the fetus; if term or near term, delivery is indicated.

381. The answer is C. (Chapter 103) Premature rupture of membranes is defined as the rupture of membranes before the onset of labor. The cause of PROM is not well understood, but there is strong evidence that inflammation from infections affecting the membranes is a precipitant. The diagnosis of PROM is made by a combination of history and physical examination. Speculum examination should be performed to look for vaginal fluid pooling in the posterior fornix. Normal vaginal fluid pH is 4.5 to 6.0; amniotic fluid has a pH of 7.1 to 7.3. Nitrazine paper turns dark blue in the presence of amniotic fluid. If vaginal fluid is placed on a slide and allowed to dry, a "ferning" pattern is diagnostic for amniotic fluid.

382. The answer is B. (Chapter 150) The TORCH infections can cause perinatal morbidity and mortality: T, toxoplasmosis; O, "other" such as human parvovirus (B19), hepatitis B infection, and syphilis; R, rubella; C, chicken pox or varicella infection; and H, herpes simplex. All have serious effects on fetuses. Patients exposed to varicella or hepatitis B who do not have adequate protective titers need immune globulin. For varicella, the immune globulin should be administered within 96 h of exposure.

383. The answer is B. (Chapter 102) Inhaled p agonists are the cornerstone of therapy. Steroids should be added in moderate and severe exacerbations, either inhaled or orally. Concomitant respiratory infections should always be considered and a chest radiograph ordered if management would be changed based on the results. Adequate oxygenation of the mother is the key to a healthy fetus.

384. The answer is D. (Chapter 101) Patients with postpartum endometritis complain of lower abdominal pain, fever, and foul-smelling discharge. The speculum examination often shows a purulent discharge but only scant discharge may be present, especially in patients with group A p-hemolytic streptococci. Cervical cultures should be obtained in all patients. Although many infections are polymicrobial, within the first 48 h postpartum, group A and B Streptococcus, Staphylococcus, and Clostridium should be considered as primary etiologies. Infections that present later are more commonly caused by chylamdia and mycoplasma.

385. The answer is B. (Chapter 246) Pelvic deformity may interfere with the normal passage of the fetus through the pelvic inlet during labor and delivery, but cesarean section is only necessary 5 to 10 percent of the time after pelvic fracture. The Kleihauer-Betke test of maternal blood is used to detect fetal cells in the maternal circulation. Although it is difficult to perform and often unavailable in emergency situations, it should be ordered to detect the rare large fetal transfusions that require specific fetal blood therapy.

386. The answer is D. (Chapter 138) Fever, hypotension, multiorgan involvement, and rash must be present to make the diagnosis of toxic shock syndrome. In addition, negative serologies for measles, leptospirosis, mononucleosis, and Rocky Mountain spotted fever are required. Negative serologic studies for streptococcal infection play no part in the diagnosis. In fact, streptococcal infections have been implicated as an etiology of the syndrome.

387. The answer is B. (Chapter 101) The transferring physician must abide by federal regulations outlined in the Emergency Medical Treatment and Active Labor Act when arranging a transfer. The most common indications for maternal transport to a tertiary perinatal facility (higher level of care) are premature rupture of membranes and preterm labor. Other reasons to initiate transport include preeclampsia, placental bleeding, and diabetes mellitus. If the patient is in active labor (having contractions and dilated to 6 cm or more), any transport is contraindicated and the physician attending the patient should prepare for immediate delivery.

388. The answer is B. (Chapter 12) Several physiologic changes of pregnancy must be considered during cardiopulmonary resuscitation (CPR). Mucosal engorgement and increased friability make the pregnant patient's airway more likely to bleed and swell during intubation. The enlarged uterus compresses the inferior vena cava when the woman is supine during CPR. The gravid uterus should be displaced off the inferior vena cava to the right by using the "human wedge," Cardiff wedge, a roll, or manual displacement. Infradiaphragmatic vessels are suboptimal for medication administration secondary to poor venous return.

389. The answer is C. (Chapter 103) In the setting of emergency delivery, bimanual pelvic examination should be performed unless placenta previa is suspected. The cervix should be checked for dilation, effacement, and presenting part. If the mother pushes before the cervix is 100 percent effaced, a serious laceration may occur. Amniotomy is not appropriate in the ED because it may result in prolapse of the cord if the baby's head is not engaged. Nuchal cords and shoulder dystocia are problems that may arise during delivery. The "turtle sign" (fetal head pulled tight into the perineum) indicates shoulder dystocia. After a generous episiotomy is performed and the bladder is emptied, suprapu-bic pressure should be applied by an assistant to aid delivery of the shoulders.

390. The answer is A. (Chapter 108) Major complications associated with laparoscopy are (1) thermal injuries to the bowel; (2) bleeding; (3) rarely, ureteral, bladder, and large bowel injury; and (4) infections or abscess formation. Traumatic injury to the bowel is generally less worrisome than thermal injury from the instruments used during the procedure. Typically when bowel trauma occurs, it is the result of a small-diameter needle and is recognized when the needle is withdrawn. Peritonitis rarely develops after this complication. Perforated viscus must be ruled out in patients with persistent or increasing abdominal pain. Air insufflated during the procedure should be absorbed within 3 days.

391. The answer is C. (Chapter 104) Genital herpes is a sexually transmitted disease caused by a DNA virus specific to humans. There are two antigenic types of herpes simplex virus (HSV), denoted HSV-1 and HSV-2. The overwhelming majority of genital infections are caused by HSV-2. In the past HSV-1 was thought to cause only oral infections, but it is now known to be responsible for up to 30 percent of the genital infections. The initial presentation of herpes occurs 1 to 45 days after exposure and is usually accompanied by constitutional symptoms such as fever, malaise, and headache. Some people have asymptomatic infections, defined as culture-positive viral shedding in the absence of symptoms or lesions. Tzanck smears identify multinucleated giant cells in up to 50 percent of cases. Cultures are positive 85 to 95 percent of the time. Acyclovir provides partial control of the signs and symptoms and accelerates healing of the lesions. This antiviral medication does not affect the frequency or severity of recurrences.

DIRECTIONS: Each question below contains five suggested responses. Choose the one best response to each question.

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