NBME Step 2 CK Form 7 Uterine atony (NBME Answers)

Retired NBME Step 2 CK Form 7 Answers

step2ck_form7/Block 2/Question#7 (reveal difficulty score)
A 36-year-old woman, gravida 1, para 1, has ...
Uterine atony 🔍 / 📺 / 🌳 / 📖
tags: repro inc

+11 upvote downvote
submitted by ∗athleticmedic(18)

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"Placenta appears complete but torn" - if it's torn and only appears complete, rather than being confirmed as complete, how can you rule out retained placental tissue? You wouldn't just assume it was complete at a complex delivery, it would require confirmation.

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drmohandes I feel you man, was guessing between the two answers as well. I think torn but complete means the whole placenta is there, but in pieces? Anyway classic scumbag NBME question writing. +4

sahusema For NBME questions, I've found that whatever is told in the findings section of a stem should be taken as 100% true even if it's an incomplete description, super confusing, or misleading. So placenta complete? → uterine atony +2

+8 upvote downvote
submitted by ∗yotsubato(1208)

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You know they could throw us a bone or something... Tell us the uterus is boggy at least, or hard, or ANYTHING AT ALL REALLY....

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saffronshawty They mentioned that the uterus is 3 cm above the umbilicus which is an indication that it's enlarged and hasn't returned to the normal post-partum size it should be, which is at the level of the umbilicus +/- 2 cm. +4

derpymd So that +1cm is the distinction here? They misdirect to suggest there may be retained placental tissue, but tell us nothing truly valuable about the state of the uterus. I think this is a poor question. +1

cinnapie @derpymd i get what you are saying but they said that the placenta is torn but complete. I guess we need to take their word for it if they say the placenta is complete and there is absolutely NOTHING left behind to cause the symptoms +1

machetebetty Also, big baby -> floppy uterus . +1

+2 upvote downvote
submitted by ∗osler_weber_rendu(160)

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Placenta appears "complete but torn???" Classic NBME shithousery!

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+1 upvote downvote
submitted by ∗step_prep5(246)

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Woman with complicated/prolonged delivery with excessive postpartum bleeding who does not have retained placenta, genital tract trauma or history of coagulopathy, and therefore most likely has uterine atony (most common cause of postpartum bleeding and commonly seen after prolonged/difficult delivery)
Causes of post-delivery bleeding is 4 T’s: (1) aTony (most common) (2) Trauma (3) Thrombin (coagulopathy) (4) Tissue (retained placenta, etc.)

https://step-prep.org/tutoring/

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krewfoo99 Yes but how do you know that the placenta is not retained? +

+0 upvote downvote
submitted by ∗usmile1(154)

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This presentation really could be either retained placental tissue or uterine atony. i think the key with these nbme questions is to go with the most likely diagnosis, and the most common cause of post partum hemorrhage is uterine atony

"At times the bulk of the placenta will deliver spontaneously or manually, but small portions or an accessory lobe may be retained. This may be suspected when the placenta appears fragmented after delivery or when there is ongoing heavy uterine bleeding. In this situation, the uterine cavity may be evaluated with manual exploration or with ultrasound. The utility of ultrasound in this situation has yet to be established, with a focal endometrial mass, particularly with Doppler flow, being the findings of interest. In one study of routine ultrasound immediately after vaginal delivery, the sensitivity for diagnosing retained placental fragments was only 44% with a positive predictive value (PPV) of 58%" https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6789409/#S0006title

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