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  #1  
Old 11-27-2011
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Question Three ObGyne Questions

1. You are asked to consult on a 31-year-old woman who is at 26 weeks’ gestation and who has had fever for 2 days. She states that she starting feeling fevers and chills approximately 3 days ago. These symptoms have worsened since that time and she has also experienced myalgias, back pain, malaise, and upper respiratory complaints. She was initially diagnosed with the flu, but her condition seems to be worsening. Her prenatal course has been otherwise uncomplicated. She has no past medical or surgical history. Her past obstetric history is significant for a normal spontaneous vaginal delivery 3 years ago. She takes no medications and is allergic to sulfa drugs. Her physical examination is significant for a temperature of 38.3 C (101.0 F) and mild abdominal tenderness. Her urine culture is negative. Her obstetrician performed an amniocentesis yesterday that demonstrated gram-positive rods. Which of the following is the most likely causative organism?

A. Clostridium difficile
B. Escherichia coli
C. Lactobacillus bulgaricus
D. Listeria monocytogenes
E. Neisseria gonorrhoeae

2. A 31-year-old woman comes to the clinic for a preoperative evaluation. She is undergoing an infertility workup and a laparoscopy is planned. She and her husband have been trying to have a child for the last 5 years, but have not had any success. Over that time period, this woman has suffered three miscarriages. Her past medical history is remarkable for anemia, a history of depression, and a deep venous thrombus suffered during her first pregnancy. Her review of systems reveals diffuse arthralgias, but is otherwise unremarkable. She is currently not taking any medications, though she does report having a drug reaction to prenatal vitamins. Early in pregnancy, she had a red facial rash across her face that spared her nasolabial folds. Physical examination today is unremarkable. Laboratory studies, with the exception of a prothrombin time elevated to two times greater than normal, are unremarkable. Which of the following studies will most likely explain this patient’s laboratory abnormality?

A. Assay for cardiolipin antibody
B. Blood smear with manual review
C. Screening for Factor V Leiden mutation
D. Ristocetin cofactor analysis
E. Serologic test for syphilis

3. A 30-year old woman has irregular menses. She reports that her last menstrual period (LMP) was 8 weeks ago. She has been experiencing vaginal spotting and left lower quadrant pain. She is afebrile. She has a normal size uterus and mild tenderness in the right lower quadrant with no rebound tenderness. A human chorionic gonadotropin (hCG) beta-subunit level of 1400 mIU/ml is reported in her records from an obstetrics visit 2 days ago. Which of the following is the appropriate management?

A. Perform a pelvis ultrasound
B. Perform a culdocentesis
C. Repeat hCG measurement in 1 week
D. Repeat hCG measurement in 24 hours
E. Refer for diagnostic laparoscopy
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Old 11-27-2011
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1 - e

2 - a



3 - d
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1-D. Listeria monocytogenes
2-A. Assay for cardiolipin antibody
3-D. Repeat hCG measurement in 24 hours
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1)(D)listeria.......sure
2) A. Assay for cardiolipin antibody....SLE hence antiphospholipid antibodies
3)A. Perform a pelvis ultrasound...ectopic pregnancy?
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D. Listeria monocytogens
A. Perform cardiolipin assay
D. Repeat hcg in 24 hrs ( her current hcg is 1400 you wont be able to know if she has an intrauterine conception with an abdomina U/S until her hcg is >6500 or you can do a vaginal U/S but then again you will have to wait for the hcg to rise >1500)
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but dont the symptoms suggest of something more than normal intrauterine pregnancy??but with second thought i too would go with u people as i remember this question was already posted long bck in this forum.not sure though......
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Quote:
Originally Posted by sonu.agarwall View Post
but dont the symptoms suggest of something more than normal intrauterine pregnancy??but with second thought i too would go with u people as i remember this question was already posted long bck in this forum.not sure though......
irregular menses + 8 week + hCG 1400 mIU/ml = ectopic pregnancy?

- The first step in the diagnosis of an ectopic pregnancy is to evaluate for an intrauterine pregnancy.
- TVUS can identify intrauterine pregnancy at a gestation of 5.5 menstrual weeks at nearly 100% accuracy. At 4.5 to 5 weeks, the first ultrasound marker of intrauterine pregnancy is a gestational sac with a “double decidual sign” (double echogenic rings around the sac). The yolk sac appears next at 5 to 6 weeks and remains until about 10 weeks. The embryo (fetal pole) and cardiac activity can be first detected at about 5.5 to 6 weeks. A potentially confounding ultrasound finding is a pseudosac.
- In the absence of a reliable last menstrual period, the hCG level is instrumental in the evaluation of ectopic pregnancy. The concept of a discriminatory zone should be used to help facilitate ultrasound findings. The discriminatory zone is defined as the level of hCG at which an intrauterine pregnancy should be visualized. With abdominal ultrasound, most radiologists use 6500 mIU/mL, but this has been further refined with the use of TVUS, reducing the discriminatory zone to 1500 to 2500 mIU/mL
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She has been experiencing vaginal spotting and left lower quadrant pain



i meant this
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Quote:
Originally Posted by sonu.agarwall View Post
She has been experiencing vaginal spotting and left lower quadrant pain



i meant this
yeap...so, the first thing we must think of is pregnancy - normal vs ectopic (vaginal spotting and no vaginal discharge)...since hCG<1500 = we cannot use TVUS (or pelvic US)
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The correct answer is D. Listeria monocytogenes is a motile, non-spore-forming, gram-positive rod that has a tendency to infect pregnant women, newborns, and immunocompromised patients. It can occur in epidemics and has been associated with the consumption of contaminated dairy products. Listeriosis is the disease caused by infection with Listeria monocytogenes. Most women with listeriosis remain asymptomatic or only mildly symptomatic. Symptoms, when they do occur, resemble those seen in a mild flu-like illness. Patients with symptomatic listeriosis complain of fever, chills, myalgias, back pain, and upper respiratory complaints. Unfortunately, whereas maternal symptoms are often mild, fetal effects can be devastating. Intrauterine infection leads to high fetal morbidity and mortality. Treatment is with ampicillin and gentamicin. Although many physicians would opt to deliver the fetus or terminate the pregnancy once listeriosis is identified, case reports suggest that antibiotic treatment without delivery of the fetus can be successful and result in a healthy mother and fetus.
Clostridium difficile (choice A) is a gram-positive anaerobic bacterium that is the major cause of colitis and antibiotic-associated diarrhea. It is not commonly associated with chorioamnionitis.
Escherichia coli (choice B) is part of the normal flora of the human intestinal tract. It is also known to cause a large number of illnesses in humans, however, including urinary tract infections, pneumonia, meningitis, diarrhea, and others. It is a gram-negative organism, not a gram-positive rod (as is Listeria monocytogenes).
Lactobacillus bulgaricus (choice C) is a gram-positive rod and one of the most common organisms used in the manufacture of yogurt. It is not considered to be pathogenic.
Neisseria gonorrhoeae (choice E) is a gram-negative organism. This patient has gram-positive rods in her amniotic fluid. The most likely causative organism therefore is Listeria monocytogenes and not Neisseria gonorrhoeae.
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The correct answer is A. This patient likely has antiphospholipid syndrome, which is sometimes associated with lupus. Antiphospholipid syndrome is an autoimmune disorder characterized by the production of moderate to high levels of antiphospholipid antibodies and specific clinical features. The most frequent clinical manifestations are thrombotic episodes, thrombocytopenia, and pregnancy loss. There are three antiphospholipid antibodies with well-established assays: the biologic false-positive test for syphilis, lupus anticoagulant and anticardiolipin. All three autoantibodies bind moieties on negatively-charged phospholipids. A serologic test for syphilis (choice E) may be positive in patients with the antiphospholipid syndrome but is not a diagnostic criterion for the syndrome.
A blood smear (choice B) may show reduced platelets but does not provide a definitive answer.
Factor V Leiden is a common cause of hypercoagulable states. This patientís presentation is most consistent with antiphospholipid syndrome, therefore screening for Factor V Leiden mutation (choice C) is not indicated.
Ristocetin assays (choice D) can be used to evaluate for Von Willebrand's disease, which often presents as easy bleeding or oozing from mucosal surfaces.
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The correct answer is D. This patient has irregular menses and an associated low hCG level. She may have a normal intrauterine gestation, with an associated corpus luteum cyst causing the left lower quadrant pain, a threatened abortion or an ectopic pregnancy. It is recommended to repeat the hCG assay in 24 hours to see if it is rising appropriately.
A pelvis ultrasound (choice A) would not be helpful in detecting the gestational sac since its sensitivity begins at 1500 mIU/ml for a vaginal ultrasound.
Culdocentesis (choice B) is an invasive procedure to be used after more information is obtained.
Repeating hCG in 1 week (choice C) may miss an ectopic pregnancy leading to tubal rupture and hemorrhage.
Diagnostic laparoscopy (choice E) would be too invasive an option at this time.
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