Vaginal Bleeding Answers 453early postpartum bleeding include uterine atony, genital tract trauma, retained
products of conception, and uterine inversion. Late bleeding episodesmay be
caused by endometritisor retained products of conception. Patients with
endometritis most often present with fever, vaginal discharge, general
malaise, and vaginal bleeding.Upon pelvic examination, the uterus will
be soft and tender to the touch. The majority of infections are caused by normal
vaginal flora, such as anaerobes, enterococci, and streptococci. Patients who
do not respond to initial antibiotic therapy may warrant broader spectrum
coverage and need to be further evaluated for a pelvic abscess or pelvic throm-
bophlebitis.
Uterine atony (a)and uterine inversion (c)are earlier causes of postpartum
bleeding. Although retained products of conception (b)is a possibility in
this patient, her presentation is more likely to be infectious. Tubo-ovarian
torsion(e)is unlikely given that the patient’s physical examination did not
reveal any peritoneal signs. This patient’s clinical picture is consistent with
an infectious etiology. If a gynecologic process is not found, other causes of
infection must be ruled out including appendicitis.
405.The answer is b.(Rosen, pp 2419-2420.)Patients presenting with a
molar pregnancytypically have severe nausea and vomiting, a uterus larger
than expected for dates, intermittent vaginal bleeding, or passage of grape-like
contents and hypertension. Risk factors include a previous history of molar
pregnancy, and very young or advanced maternal ages. Typically, laboratory
results reveal anemia on a CBC, β-hCG higher than expected, and an
ultrasound that shows intrauterine echogenic material. Treatment includes
dilation and curettage with future monitoring and evaluation for the devel-
opment of choriocarcinoma.
Ectopic pregnancy (a)can be ruled out with the ultrasound evaluation.
Ovarian torsion (c)can also be ruled out given the sonogram which would
show good Doppler flow to both ovaries. Abruptio placentae (d)is unlikely
given the early stage of this pregnancy. Hyperemesis gravidarum (e)is a
syndrome of intractable nausea and vomiting that occurs early in pregnancy,
but is generally not associated with significant changes in vital signs or
abnormal findings on ultrasound.
406.The answer is c.(Rosen, pp 2413-2416.)Inevitable abortionsare
diagnosed in first-trimester bleedingwith an open cervical osbutno
passage of fetal products.Determining whether the internal os is open is
often misleading and confused with the normally distended external os. It is