Pregnancy: Acute Medical / Surgical Complications, Free CME Quiz
This week's Med-Challenger free CME quiz - Acute Pregnancy Complications - the quick quiz covers the diagnostic workup of pulmonary embolism in pregnancy, the diagnosis and treatment of Chlamydia trachomatis infection during pregnancy, the appropriate management of painless vaginal bleeding in the first trimester, and the management of ruptured ectopic pregnancy.
A free Endocrine Disorders question included below. The full Acute Pregnancy Complications CME quiz is free online for a limited time. You can earn AMA CME credit and ANCC contact hours. Top the leaderboard! Play now.
You must be signed in to earn CME credits, get feedback, and rank.
When you create a free Med-Challenger account, you'll get a free 100-question board review question bank in your specialty with 5 CME credits, instantly!
Get Notified of new QQ's
QQ221003: Disorders of Hemostasis
Here's this week's sample CME board review question on Acute Pregnancy Complications:
A 37-year old G1P0 woman at 38 weeks gestation, with a history of obesity and smoking, presents with sudden-onset dyspnea and chest pain.
On arrival, she is awake and alert, but ill-appearing, and is using her accessory muscles of respiration.
Temperature is 99.2°F (37.3°C), heart rate 130 beats/min, blood pressure 95/65 mmHg, respiratory rate 28/min, oxygen saturation 92% on room air.
Her lower extremities are mildly edematous bilaterally, and nontender.
A chest X-ray is unremarkable, and serum D-dimer is 800 ng/mL.
According to the Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism, which of the following is the most appropriate next step?
Anticoagulate with warfarin
Anticoagulate with IV heparin
Obtain compression ultrasonography
Obtain a pulmonary CT angiogram
See the Answer Here:
The correct answer is:
Obtain a pulmonary CT angiogram
Discuss the diagnostic workup of pulmonary embolism in pregnancy.
CT angiogram or V/Q scanning, not compression ultrasonography, are the recommended definitive imaging studies in the diagnosis of pulmonary embolism in a pregnant patient WITHOUT signs and symptoms of a deep vein thrombosis (DVT). In patients WITH signs and symptoms of a DVT, compression ultrasonography would be the first study.
Thromboembolic disease accounts for almost 20% of obstetric mortality, making it the leading cause of death in pregnancy. The risk of venous thromboembolism (VTE) increases during pregnancy to five or six times that of nonpregnant women, and is especially high in patients with histories of obesity, smoking, age >35 years, and/or pre-existing hypercoagulable state.
Anticoagulation should be given only after the diagnosis of VTE is confirmed. In such cases, heparin or low-molecular weight heparin is appropriate, as warfarin is contraindicated in pregnancy (due to teratogenic effects and high risk of fetal hemorrhage).
In BOTH pregnant and nonpregnant patients, clinical signs of PE (pain, tenderness, and swelling in the lower extremities, tachycardia, dyspnea, and pleuritic pain) are so nonspecific that they do not allow for a purely clinical diagnosis of PE. D-dimer by itself is not recommended in pregnancy to exclude VTE, as it is insufficiently sensitive in pregnant patients. Radiation studies are a concern in pregnant patients due to the inherent radiation exposure to the fetus and the maternal breast tissue.
In 2019, a prospective, multicenter study suggested that the YEARS algorithm, using adapted Wells criteria, could avoid unnecessary pulmonary CT angiograms in pregnant patients who presented with possible PE. Similar to the Wells algorithm, the YEARS algorithm first of all determines risk of PE on the basis of various criteria (in the case of the YEARS algorithm, these are: hemoptysis, clinical evidence of DVT, high index of suspicion for PE, and D-dimer). The authors reported that use of this modified algorithm avoided CT angiography in up to 65% of pregnant patients, an important finding considering the risks of radiation to the fetus.
Another key point of this study is that it is not always appropriate to first do compression ultrasonography in pregnant patients who might have a VTE.
According to the YEARS algorithm, the patient in the above scenario would require a CT angiogram because she has at least one YEARS criterion (high index of suspicion for PE), and a D-dimer >500 ng/mL.
The study found that the yield is too low in patients, who - key point – DO NOT have clinical signs of a deep vein thrombosis. In this surprisingly large subgroup, only 1% had positive compression ultrasound findings (this includes looking for proximal vein thrombosis anywhere above the knee). In other words, 99% of pregnant patients in this study without signs of DVT moved on to CT angiogram or V/Q scanning after their ultrasound compression study.
Based on the results of this large study, CT angiogram or V/Q scan are indeed the recommended first line studies for pregnant patients without signs of DVT. For patients WITH clinical signs of DVT, a compression ultrasound remains the first study.
Clinically speaking, nobody would fault a physician for getting a compression ultrasound; it would just be a wasted study that does not alter outcome in 99% of this rather large subcategory of patients (pregnant without signs of DVT).
- In the YEARS study, only 7% of pregnant patients WITH signs and symptoms of DVT had a positive compression ultrasound study, so even in this group, 93% go on to CT angiogram or V/Q scanning.
- In another recent study (2018), the risk of early breast cancer was found to be similarly low after ventilation–perfusion scanning and CT pulmonary angiography, which supports the notion that both imaging methods are valid options in patients without cardiopulmonary disease.
- The YEARS study found that their algorithm prevented unnecessary radiation studies in 46% of patients during the second trimester, and 32% of patients during the third trimester. This decreasing specificity of the algorithm is due to the physiological rise in the d-dimer level that commonly accompanies the later part of pregnancy.
- The YEARS algorithm leads to a reduced detection of potentially clinically irrelevant subsegmental pulmonary embolism, leading both to a shorter visit time and reduced costs in the emergency department.
Salhi BA, Nagrani S. Acute Complications of Pregnancy (Chapter 178). Marx JA, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice, 9th ed., 2018.
Van der Pol LM, Tromeur C, et al. Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism. N Engl J Med 2019, 380: 1139-1149.
Burton KR, Park AL, Fralick M, Ray JG. Risk of early-onset breast cancer among women exposed to thoracic computed tomography in pregnancy or early postpartum. J Thromb Haemost 2018;16:876-8
Play the full Med-Challenger Quick Quiz for CME Credit:
Every free board review "Question of the Week" is just a sampling of a larger set of free board review questions featured in Med-Challenger's latest CME Quick Quiz.
Our insanely popular CME Quick Quiz provides FREE board review questions and the opportunity to earn free CME credits every week. It's a fun way to stay up-t0-date and see how your knowledge ranks with peers. All you need is a free online Med-Challenger account. Most recent 5 quizzes are available. Sign up now.
Med-Challenger provides online medical education products and services to physicians, nurses, and other medical specialists as well as medical training programs and healthcare groups world-wide via its web-based medical education library and world-class assessment platform at challengercme.com.
More from Med-ChallengerThe Leader in Online Board Review, CME Courses, and Medical Education
Did you like this?
Get more free medical Q&A and informative CME articles.
Subscribe to the Medical Education Blog
More from Med-Challenger's Medical Education Blog
Acute Pregnancy Complications – Acute Medical / Surgical Complications in Pregnancy, Free CME Quiz – Earn AMA and ANCC Credits FreeFebruary 1, 2023
Woman 9 Weeks Pregnant with Lethargy and Weight Gain – Clinical Patient Case of the WeekJanuary 31, 2023
Woman with Diabetes, Eye Pain, Headache, and Vomiting – Clinical Patient Case of the WeekJanuary 13, 2023
Board Review & CME Offers
Med-Challenger provides online medical education, top-rated board review courses, annual MOC and CME credit solutions for physicians, nurses, PAs and students. Take advantage of our current offers.
2023 New Year Sale
Save 10% with code:
including PRO bundles.
Some restrictions apply.
Enter code at checkout. SHOP NOW.
PROCareer Value Bundles
in your specialty.
Useful every year.
Ideal use your CME budget.