Experience the Quality With Free USMLE Exam Questions That Helps Candidates Pass

Hypertension diagnosed before 20 weeks of gestation is defined as chronic hypertension, regardless of whether it was previously recognized. Gestational hypertension develops after 20 weeks without proteinuria or end-organ damage. Preeclampsia involves hypertension after 20 weeks plus proteinuria or end-organ dysfunction. Eclampsia is preeclampsia complicated by seizures. Chronic hypertension in pregnancy increases the risk of preeclampsia, placental abruption, fetal growth restriction, and preterm delivery. Management includes antihypertensives safe in pregnancy (labetalol, nifedipine, methyldopa) and monitoring for complications. ACE inhibitors and ARBs are contraindicated due to teratogenicity. Close surveillance is crucial throughout pregnancy.

Autonomy is the principle that patients have the right to make informed decisions about their own care. Withholding information at the family’s request undermines the patient’s autonomy, even if the intent is to prevent distress. Beneficence refers to acting in the patient’s best interest, and nonmaleficence means avoiding harm. Justice refers to fairness in healthcare. While cultural contexts sometimes emphasize family-centered decision-making, ethically, physicians must respect patient autonomy unless the patient explicitly delegates decision-making authority. Best practice is to ask patients upfront about their preferences for disclosure and decision involvement.

Primary postpartum hemorrhage most commonly results from uterine atony, in which the myometrium fails to contract effectively, leaving uterine spiral arteries patent. A soft, enlarged (“boggy”) uterus with heavy bleeding shortly after delivery is diagnostic. First-line treatment is immediate bimanual uterine massage to stimulate contraction coupled with uterotonic therapy—oxytocin is the agent of choice due to rapid onset and favorable safety profile. If bleeding persists, second-line uterotonics include methylergonovine (contraindicated in hypertension or preeclampsia due to vasoconstriction) and carboprost (contraindicated in asthma due to bronchospasm risk). Tranexamic acid can be used adjunctively to stabilize clots but is not a substitute for uterine contraction. Broad-spectrum antibiotics (choice A) treat postpartum endometritis, which presents with uterine tenderness and fever, not acute atony. Additional measures for refractory hemorrhage include intrauterine balloon tamponade (Bakri balloon), uterine artery embolization, or surgical interventions (B-Lynch suture, hysterectomy) depending on response and stability. Rapid assessment with uterine massage and oxytocin is life-saving and reduces transfusion needs.

Pheochromocytoma is a catecholamine-secreting tumor of chromaffin cells in the adrenal medulla. Classic symptoms are episodic headache, sweating, and palpitations, with paroxysmal or sustained hypertension. Diagnosis is confirmed by elevated plasma or urinary catecholamines and metanephrines. Adrenal adenomas cause hyperaldosteronism or Cushing syndrome, not catecholamine excess. Paragangliomas are extra-adrenal catecholamine-secreting tumors with similar presentation but different location. Adrenal cortical carcinoma may secrete cortisol, androgens, or estrogens. Pheochromocytoma is associated with MEN2A/2B and von Hippel–Lindau disease. Treatment requires alpha-blockade (phenoxybenzamine) before beta-blockade, followed by surgical resection. Failure to block alpha before beta can precipitate hypertensive crisis due to unopposed vasoconstriction.

Atrial fibrillation (AF) is the most common arrhythmia, characterized by chaotic atrial electrical activity leading to an irregularly irregular rhythm with absent P waves. Risk factors include hypertension, hyperthyroidism, valvular disease, and alcohol use (“holiday heart”). Atrial flutter presents with sawtooth flutter waves and regular rhythm. Ventricular tachycardia shows wide QRS complexes and is life-threatening. Supraventricular tachycardia presents with sudden paroxysmal palpitations and narrow QRS but with regular rhythm. AF increases risk of thromboembolism and stroke, requiring anticoagulation based on CHA₂DS₂-VASc score. Rate control (beta-blockers, calcium channel blockers) and rhythm control (antiarrhythmics, ablation) are key management strategies.