49. Labor is a series of events affected by the coordination of the five essential factors. One of these is the passenger (fetus). Which are the other four factors?
1. Contractions, passageway, placental position and function, pattern of care
2. Contractions, maternal response, placental position, psychological response
3. Passageway, contractions, placental position and function, psychological response
4. Passageway, placental
position and function, paternal response, psychological response
The three signs of placenta separation after delivery include which of the following?
(A) a gush of blood, a change in uterine shape from discoid to globular, and lengthening of the
umbilical cord
(B) descent of the fundus, a gush of blood, maternal valsalva
(C) a darkening of the perineum, a change in uterine shape from discoid to globular, and a blanching
in the umbilical cord
(D) a rise in maternal blood pressure 10 mm
Hg, vaginal retraction, and lengthening of the umbilical
cord
(E) descent of the fundus, vaginal retraction, and blanching of the umbilical cord
(A)
Conditions of inappropriate prolactin secretion cause nongestational lactation, referred to as galactorrhea. The most common cause is a prolactin-secreting pituitary adenoma (prolactinoma). Although one-quarter of the general population harbors a pituitary adenoma (most of which are biologically inert),
about one-half of patients with symptomatic hyper-prolactinemia have radiologic evidence of a pituitary adenoma. Prolactinomas cause an elevation in circulating prolactin levels. A concomitant suppression of pulsatile GnRH secretion results in amenorrhea. Prolonged estrogen deficiency under these conditions increases the risk of osteoporosis since estrogen plays a role in inhibiting bone reabsorption. Primary hypothyroidism accounts for about 3% to 5% of patients with symptomatic
hy-perprolactinemia. The compensatory increase in thyrotropin-releasing hormone (TRH) stimulates prolactin release, causing galactorrhea and/or amenorrhea. These symptoms may be the only manifestation of hypothyroidism. Other less common conditions associated with hyperprolactinemia include the following:
• Hypothalamic tumors (e.g., craniopharyngioma), via interruption of dopamine release
• Medication: Exogenous estrogen (OCs), dopaminergic antagonists (phenothiazines, tricyclic
antidepressants, reserpine, alpha-methyldopa), opiate peptide derivatives (meperidine), histamine
(H2-receptor) antagonists (cimetidine), and serotonergic agonists (amphetamines)
• Areolar neural stimulation (prolonged suckling, herpes zoster, chest surgery) • Renal failure, via reduced metabolic clearance of prolactin
• Ectopic prolactin secretion (bronchogenic carcinoma, hypernephroma)
D)
Important prognostic indicators of survival from endometrial carcinoma include (1) histologic tumor type, (2) grade of tumor differentiation, (3) lymphatic/hematogenous spread, and (4) stage of disease at the time of detection. The histologic types papillary serous and clear cell confer the highest risk of poor prognosis. They are biologically more aggressive tumors. They have a higher propensity for lymphovascular invasion, and intraperitoneal as well as extra-abdominal spread. Stage of disease is inversely correlated with 5-year survival rate (stage I, 86%; stage II, 66%; stage III, 44%; stage IV, 16%). In stage I disease, depth of myometrial invasion by tumor is an important prognostic factor. Tumor penetration beyond the middle half of the myometrium adversely affects survival and relapse rates. Malignant cells in peritoneal washings are found in 12% to 15% of women with early disease by clinical assessment and reduce the chance for survival. Other tumor indicators of poor prognosis are size (>2 cm), absence of sex steroid receptors, and DNA ploidy. Many of these prognostic indicators are interrelated and occur together. Five-year survival rates range from 95% (in women with well- differentiated tumors that do not invade the myometrium) to 20% (in patients with poorly differentiated tumors that invade deeply into the myometrium). CA-125 may be of value only in the case of advanced disease for follow-up of these patients.
(D)
Primary infection with the varicella-zoster virus causes chickenpox, which has an attack rate of 90% in seronegative individuals. Fortunately, over three-quarters of adults are immune from prior symptomatic or asymptomatic infection. Therefore, the best course of action is to determine whether this patient is immune. If so, nothing more need be done. If not, then administration of VZIG within 96 hours of exposure is recommended to attenuate varicella infection. The varicella vaccine, a live, attenuated vaccine, is not recommended for pregnant women and would not be effective in preventing infection after exposure has already occurred. Finally, IV acyclovir is recommended for the treatment of varicella pneumonia, which has been found to lower the mortality rate in pregnancy from 35% to 15%.
A 39-year-old woman presents complaining of severe, low abdominal-pelvic pain that began the day after her menses ended. She has noticed some increase in vaginal discharge. Her social history shows
she and her late husband had been medical missionaries throughout their entire lives. He was her only sexual partner, and since his death 1 year ago, she has not had intercourse. Physical examination shows a temperature of 102°F. She is on the examining table on her side, doubled over, and clutching her abdomen with both arms. She has abdominal tenderness with rebound (right greater than left), cervical motion tenderness (greatest on rectal examination), and mild tenderness in the area of the
right adnexa with no masses felt. Gram's stain of her cervix shows a "few WBCs"; WBC is 14, 400 (normal 3,600- 10,000), and an ESR of 47 mm/h (normal 0-25). A urine pregnancy test is negative. What is the next logical step in evaluation of this patient?
(A) admit her to the hospital with presumed PID, begin parenteral antibiotics, and wait 24 to 48 hours to assess her progress
(B) perform culdocentesis
(C) perform a pelvic ultrasound
(D) order a computed tomography (CT) scan of the
abdomen and pelvis
(E) take her to the operating room for diagnostic laparoscopy