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231 Cards in this Set
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A 24 year old primagravida is seeing you for her first prenatal visit. After confirming her pregnancy, you take a complete history and perform a physical exam. She has had type 2 diabetes for 6 years and has been on oral meds for blood sugar control. Her blood glucose level today is 110mg/dL. After delivery her newborn will be at risk for:
A. elevated blood glucose B. low hematocrit C. low calcium D. elevated potassium E. low bilirubin |
C. low calcium- aslo at high risk for delivering a baby with respiraotyr distress, hypoglycemia, polycythemia and hyperbilirubinemia
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A 22 year old woman, G2P0, at 22 weeks gestation presents for her prenatal visit. She had diabetes prior to becoming pregnancy and was taking an oral hypoglycemic agent to control her blood sugars. Since becoming pregnant, she has been self administering regular and NPH insulin. Today, she reports low back pain. Her fundus is 21cm and she has 1+ glucosuria on her dipstick. Fasting blood sugar is 93mg/dL and her 2 hour postprandial sugar is 119mg/dL. What is the next step in management.
A. Adjust her insulin B. Measure maternal serum AFP C. Perform fetal ultrasound D. Perform fetal echocardiograph E. Perform MRI of spine |
D. Perform fetal echo- Women with pre-existing diabetes are high risk. Fetal echo should be performed between 20-22 weeks. She is below glucose levels. Maternal serum AFP is only useful during weeks 15-20.
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28 year old G2P1, at 20 weeks gestation presents with increased sweating and palpitations. Her fundus measures 17cm, T=98.8, BP= 115/80, P=132, R=16. She is found to have elevated total T4, total T3, and free T4, and TSH less than 0.1. What is the initial management?
A. Propranolol B. Methimazole C. Propylthiouracil D. Potassium iodide E. Fetal ultrasound |
A. Propranolol- beta blockers are initial treatment of choice for tachycardia and palpitations.
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18 year old woman, G3P2, at 28 weeks of gestation, is admitted with right sided back pain, fever, chills and severe nausea. She has bilateral CVA tenderness, with greater discomfort on the right side. Temperature is 102.6, with normal CBC, BUN and creatinine. Urinalysis revealed more than 100 WBC/hpf. After three days of culture appropriate antibiotics, her temperature is still 103. The next step is...
A. repeat urine culture B. repeat CBC C. change antibiotics D. perform an ultrasound E. perform an intravenous pyelogram |
D. Scenerio presented is pyelonephritis not responding to treatment. This finding should always prompt radiologic eval to rule out an abscess or renal calculi. The ultrasound is the least invasive.
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20 year old woman just delivered a viable male neonate at 38 weeks after being a restrained passenger in a car accident. Upon arriving at the ED, she was sent to labor and delivery. There she began having vaginal bleeding and then went into labor spontaneously. The estimated blood loss with delivery was 900mL, and now she is stable. After obtaining her prenatal info, you realize she is Rh negative and antibody D negative. The next step is:
A. Perform a CBC B. Transfuse packed RBC C. Perform Kleihauer Betke test D. Give additional Rh immune globulin E. Assess neonatal Rh antigen status |
E. Asses neonatal Rh antigen status- to manage an Rh negative, unsensitized (antibody negative) patient, you must know the status of the baby. If the baby is Rh negative, no worries. If they baby was Rh positive, we would have to quantitate the amount of fetomaternal blood transfusion by doing a Kleihauer Betke test and then give additional to mom if necessary.
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23 year old G1P0 presents at 28 weeks gestation. No known medical history. Denies blurry vision, epigastric or right upper quadrant pain, severe headache or trouble breathing. Her BP and urine protein dipstick results for the past three visits are:
Visit 1: 105/60, dip=0 Visit 2: 110/65, dip=1+ Visit 3: 115/68, dip= 1+ Today her BP is 120/75 and dip is trace. She reports lots of fetal movement. Her fundus measures 25cm. Lungs are CTA bilaterally. DTR are 2+ symmetrically. Other lab values include AST=340U/L, ALT= 200U/L. Her most accurate diagnosis is: A. Chronic hypertension B. Gestational hypertension C. Mild preeclampsia D. Severe preeclampsia E. Superimposed preeclampsia on chronic hypertension |
D. Severe preeclampsia
WTF, really? Apparently, although all of her blood pressure values are normal and she only has mild proteinuria, the fact that her blood pressure has been rising and that her liver enzymes are high make this severe preeclampsia. |
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20 year old primigravid woman at 37 weeks of gestation presents to clinic. She reports active fetal movement and abdominal pain. BP is 162/103 initially and she has 2+ proteinuria. She has diffuse tenderness over her abdomen. Her fundus is 36cm above the symphysis pubis. You send her to labor and delivery where they redraw her labs as follows BP= 166/104 and there is 3+ proteinuria on urine dipstick. Her cervix is closed, long, firm and posterior and the fetal vertex is high. What is the next step in management?
A. oxytocin B. prostaglandin analog and magnesium sulfate C. magnesium sulfate D. methyldopa E. hydralazine |
B. prostaglandin analog and magnesium sulfate- she has severe preeclampsia (BP, protein and abdominal pain) --> induce her with prostaglandin and prophylax against seizures with magnesium
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26 year old primagravida at 35 weeks complains of mild headache and facial edema. Her blood pressure is 160/100 and her reflexes are brisk. You suspect preeclampsia. Urinalysis is likely to show...
A. proteinuria B. hematuria C. glycosuria D. ketonuria E. leukocytes |
A. proteinuria
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Preeclampsia will become eclampsia with the addition of what?
A. Severe headache B. Clonus C. Grand mal seizures D. Petit mal seizures E. Visual scotomata |
C. Grand mal seizures
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38 year old black woman, G1 presents for a routine visit at 39 weeks gestation. Her blood pressure is persistantly 140/90, her urine protein is 2+. Her cervix is 2cm dilated and 90% effaced with fetal vertex at 0 station. What is the next appropriate management?
A. Immediated c section B. Induction of labor C. Admission to hospital for observation B. Outpatient observation |
B. induction of labor- mild pregnancy induced hypertension at term, because she has proteinuria, it can further be classified as preeclampsia; the indicated treatment for PIH of any severity at term is delivery. Because her cervix is favorable, induction of labor is the preferred method
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A 25 year old Asian woman, G2P0 presents at 33 weeks gestation for a routine visit. Her blood pressure is 150/100 and her protein is 3+. She reports no RUQ pain or visual scotomata. What is the next appropriate management?
A. immediate c section B. induction of labor C. admission to hospital for observation D. outpatient observation |
C. admission to hospital for observation- HTN and proteinuria suggest preeclampsia, she is preterm. with mild disease in a preterm patient, observation and evaluation for severe disease is indicated, because things could get bad, admit her
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A 26 year old G2P1 at 32 weeks gestations comes in. She says her systolic blood pressures have been in the high 170s and her diastolic pressures have been in the low 110s. She denies abdominal pain, visual disturbance or headaches. Her blood pressure in labor and delivery is 150/98 and she has 1+ proteinuria. Which of the following is the most appropriate management?
A. Induce labor- vaginal delivery B. C section C. Phenytoin D. labetalol E. Betamethasone |
E. betamethasone- she has mild preeclampsia at 32 weeks (preterm); because definitive management of preeclampsia is delivery, you have to weight benefit to mom and fetus. You can just monitor to see if things get worse, while giving steriods to speed fetal lung maturity. Also, put her on magnesium, anyone with preeclampsia needs to be on seizure prophylaxis.
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35 year old G5P1 at 6 weeks gestation comes in. She has a 6 year history of essential hypertension controlled on a diuretic. You change her blood pressure meds to methyldopa and ask her to use it throughout the pregnancy. Which is the best reason for using methyldopa in a patient with chronic hypertension during pregnancy?
A. it is the best antihypertensive during pregnancy B. it decreases the risk of IUGR in the fetus C. It decreases the risk of abruption placentae D. It decreases the risk of maternal end organ damage E. It increases uteroplacental perfusion |
D. treatment of HTN during pregnancy reduces the risk of maternal morbidity by preventing end organ damage. whether therapy reduces perinatal mortality is controversial.
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Which of the following is an independent risk factor for pregnancy induced hypertension?
A. multiparity B. family hisotry of chronic hypertension C. older than 40 D. age younger than 20 E. history of seizure disorder |
C. age older than 40
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Which might be found in a patient with mild preeclampsia?
A. oligohydraminos B. proteinuria in excess of 3g/24h C. thrombocytopenia D. intrauterine growth restriction E. elevated transaminases |
B. proteinuria in excess of 3g/24h
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32 year old G2P2 presents to clinic with chronic abdominal and pelvic pain. Pain is intermittent, worse when she lies on her left side, nonradiating and occurs at different times throughout her menstrual cycle. PSx is significant for appendectomy 4 years ago d/t ruptured appendix. On exam, you note the appendectomy scar, bowel sounds in all four quadrants. Abdomen is diffusely tender to palpation, especially in the lower quadrants. Pelvic exam is unremarkable. Most likely diagnosis is:
A. Torsion of ovarian cyst B. Mittelshmerz C. Adhesion D. Psychogenic cause E. PID |
C- adhesion- d/t previous surgery and the fact that the appendix was ruptured, there is a high likelihood of adhesive disease
the fact that the pain is positional and not related to the menstrual cycle also suggests adhesions |
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19 year old female G0 has had increasingly severe menstrual cramps since menarch. Her pain is worse around menses, but she also complains of dyspareunia and worse pain with movement. Denies NVD. Her pelvic pain is most likely to be:
A. gastrointestinal B. gynecologic C. gynecologic or urologic D. urologic E. gynecologic, urologic or MSK |
E. pain is worse with menses, intercourse, and movement, therefore she could have a gynecologic, urologic or musculoskeletal cause of her symptoms
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18 year old nulligravid woman presents with painful periods. She only has pain during the first two days of her period, which are regular. Pain is midline and 2cm below the umbilicus. Motrin helps. Her pain is transmitted by...
A. Sympathetics to T10 B. Sympathetics to T11 C. Parasympathetics to S1 D. Parasympathetics to L1 E. Pudendal nerve to S2-4 |
B. uterus is innervated by sympathetics (not parasympathetics) which go to spinal cord segments T10, 11, 12, L1. Because patients pain is slightly below the umbilicus, the pain reaches T11.
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33 year old G5P4 therapeutic abortion 1, presents to clinic with LLQ pain for 2 days. Pain was intermittent but is now constant, nonradiating and not associated with any other symptoms. LMP was 2 months ago. She had a tubal ligation 2 years ago and a cholecystectomy 7 years ago. Vitals normal. Abdominal exam shows scar in RUQ, scar in umbilicus and RLQ, present bowel sounds, tenderness to palpation in LLQ, no rebound tenderness. Pelvic exam shows uterus of normal size, shape, contour and no masses. What is the next step in her management?
A. laparoscopy B. laparotomy C. antibiotics D. naproxen E. serum BhCG |
E. serum hCG- ectopic pregnancy is possible given the patients history of tubal ligation
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25 year old G4P3, spontaneous abortion, presents to your clinic fo rthe fist time reporting pelvic pain. She has had this pain for the last 10 years and has seen several physicians. The pain is continuous and dull with intermittent exacerbations. It occasionally radiates to her lower back and down her thighs. Nothing she takes helps. Pain is not related to her menstrual cycle, which occurs only a few times/year. She has dyspareunia, asthma, PUD and depression. She has had 3 hospitalizations in the past 10 years for suicide attempts. She has a history of sexual abuse when she was 13. Everything looks normal.
A. Endometriosis B. Uterine fibroids C. Mittelschmerz D. Pelvic adhesions E. psychogenic cause |
E. bitch is craaaaaaaazy
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26 year old female presents to the ER with RLQ pain. She is taken to the OR for presumed appendicitis. At the time of her surgery, her appendix is normal, but the surgeon sees a large mass on the right ovary and removes the ovary. Frozen section on the mass shows a corpus luteum. Immediately after the surgery her pregnancy test is found to be positive and she is by dates 6 weeks pregnant. You are called as the consulting gynecologist. Your main concern is:
A. The hCG level should double over the next 2 days since she is 6 weeks pregnant B. Having one ovary will affect her ability to produce hormones C. Removing the corpus luteum will affect the pregnancy D. Estrogen production will not be affected E. She should still have an ectopic pregnancy |
C. Removing the corpus luteum will affect the pregnancy
The luteum is needed to produce progesterone until 8 weeks, since she is only 6 weeks, this is no good. Progesterone supplementation should be initiated to support the pregnancy. |
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36 year old G3P2 at 8 weeks gestation, presents to the clinic reporting painless vaginal bleeding. Vitals are T=99.9, BP=162/94, P=100, R=18. Her uterus is consistent with a 14 week pregnancy. Her serum hCG is 320,000IU/L. Which of the following endocrine glands is most likely to be affected by the hCG?
A. adrenals B. hypothalamus C. ovary D. parathyroid E. thyroid |
E. thyroid
the alpha subunit of hCG is identical to the alpha subunit of TSH and can stimulate the production of thyroid hormone --> hyperthyroidism |
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29 year old woman who is pregnant calls you for advice. She has just found out that her hCG level is elevated. Which is true?
A. hCG can stimulated production of TRH, causing hyperthyroidism B. high levels of hCG are indicative of an ectopic pregnancy C. high levels of hCG in the second trimester is indicative of molar pregnancy D. high levels of of hCG in the second trimester is the most sensitive marker for Down syndrome E. hCG is part of the quadruple screen in the first trimester |
D. high levels of hCG in the second trimester is the most sensitive marker for Down syndrome
**high hCG in the first trimester is suggestive of molar pregnancy, hCG is part of the quad screen in the second trimester, not the first, low hCG is suggestive of ectopic pregnancy |
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Estrogens are produced by the mother, fetus, and placenta. Which of the following is true?
A. estradiol accounts for 80% of the estrogen produced during pregnancy B. estriol is produced primarily by the placenta C. anencephaly is associated with a normal level of estriol D. estrogen suppresses oxcytocin secretion E. estrone accounts for 80% of the estrogen produced during pregnancy |
B. estriol is produced primarily by the placenta
estriol accounts for 80% of the estrogen produced during pregnancy, anencephaly is associated with a decreased level of estriol, estrogen increases oxytocin secretion to allow breast feeding |
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Which hormone increases myometrial gap junction formation in pregnancy?
A. hCG B. hPL C. Prolactin D. Progesterone E. Estriol |
E- estriol
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Which hormone suppresses maternal lymphocyte activity in pregnancy?
A. hCG B. hPL C. Prolactin D. Progesterone E. Estriol |
D- progesterone
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Which hormone is necessary for development of male external genitalia in pregnancy?
A. hCG B. hPL C. Prolactin D. Progesterone E. Estriol |
A- hCG
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Which hormone is the most sensitive marker for abnormal karyotype in pregnancy?
A. hCG B. hPL C. Prolactin D. Progesterone E. Estriol |
A- hCG
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Which hormone elevates ketone levels in pregnancy?
A. hCG B. hPL C. Prolactin D. Progesterone E. Estriol |
B- hPL
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Which hormone is produced by the uterus in pregnancy?
A. hCG B. hPL C. Prolactin D. Progesterone E. Estriol |
C- prolactin
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Which hormone inhibits lactation during pregnancy?
A. hCG B. hPL C. Prolactin D. Progesterone E. Estriol |
E- estriol
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A lack of this hormone can cause spontaneous abortion in the first trimester.
A. hCG B. hPL C. Prolactin D. Progesterone E. Estriol |
D- progesterone
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Lack of this hormone is associated with an enzyme deficiency in the placenta.
A. hCG B. hPL C. Prolactin D. Progesterone E. Estriol |
E- estriol
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Elevated levels of this hormone are associated with a twin pregnancy.
A. hCG B. hPL C. Prolactin D. Progesterone E. Estriol |
A- hCG
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Anencephaly causes lack of production of this hormone.
A. hCG B. hPL C. Prolactin D. Progesterone E. Estriol |
E- estriol
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24 year old G4P3 at 18 weeks gestation dated by her last period gets an ultrasound. Her first pregnancy was complicated by delivery of an infant with spina bifida. Her other two pregnancies were uncomplicated. After confirmation of her gestational age using biparietal diameter, abdominal circumference, and femur length, you can scan the fetal ductus venosus. Using ultrasound, which structure would you see leading into and out of the ductus venosus respectively?
A. pulmonary artery; aorta B. IVC; portal vein C. umbilical vein; portal vein D. portal vein; inferior vena cava E. right atrium; left atrium |
D. portal vein; inferior vena cava
the ductus venosus being oxygenated blood from the placenta to the inferior vena cava. blood from the portal vein flows into the ductus venosus, thereby decreasing the overall oxygen content of the blood entering the inferior vena cava. thus, blood flowing into the right ventricle is not as well oxygenated as blood coming directly from the placenta. |
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37 year old woman G1P1 just delivered at term a viable male weighting 3980g with APGARs of 9 and 9 at 1 and 5 minutes. Delivery was via spontaneous vaginal delivery without any complications. After clamping of the umbilical cord, the baby takes his first breath. Which event(s) is/are directly responsible for the most efficient oxygenation of blood inside the lungs?
A. Closure of the foramen ovale B. Closure of the ductus arteriorsus C. Closure of foramen ovale and ductus arteriosus D. Closure of umbilical vein and artery E. Closure of ligamentum arteriosum and ligamentum teres |
C. closure of the foramen ovale and ductus arteriorsus
resistance in the pulmonary vessel is reduced after the first breath, thus blood can flow through the pulmonary artery to the lungs to become oxygentated |
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One student claims that the fetal cardiac output is at least 2 times that of the adult cardiac output since the average heart rate in the fetus is 140 bpm. The second student claims that the fetal oxygen consumption is probably probably half of adult oxygen consumption because fetal hemoglobin has twice the affinity for oxygen than adult hemoglobin. the cardiac output and oxygen consumption in a fetus are approximately what compared to an adult?
A. 2;2 B. 3;3 C. 1/2;1/2 D. 1/3;1/3 E. 2; 1/2 |
B. 3;3
Fetal cardiac output is approximately 200mL/kg/min, whereas an average adult's cardiac output is 70mL/kg/mL. Fetal oxygen consumption is 8mL/kg/min, whereas adult oxygen consumption is approximately 3mL/kg/min |
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The most oxygenated blood is found in which part of the fetal circulation?
A. Ductus venosus B. Portal vein C. IVC D. Ductus arteriorsus E. Descending aorta |
A. The umbilical vein carries the most well oxygenated blood from the placenta. The ductus venosus carries slightly less oxygen because it mixes with the portal with the portal venous blood.
The IVC carreis blood from both the ductus venosus and the systemic circulation, therefore carrying lessoxygen overall than the ductus venosus. The ductus arteriorsus and descending aorta receive blood returning from the systemic circulation. |
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How is glucose transferred across the placenta?
A. Endocytosis B. Facilitated transport C. Passive diffusion D. Active transport E. Ion pumps |
B. facilitated transport
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How is iron transferred across the placenta?
A. Endocytosis B. Facilitated transport C. Passive diffusion D. Active transport E. Ion pumps |
A. endocytosis
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How are amino acids transferred across the placenta?
A. Endocytosis B. Facilitated transport C. Passive diffusion D. Active transport E. Ion pumps |
D. active transport
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How is carbon dioxide transferred across the placenta?
A. Endocytosis B. Facilitated transport C. Passive diffusion D. Active transport E. Ion pumps |
C. passive diffusion
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During which trimester is there the highest concentration of hemoglobin containing two alpha and two beta chains?
A. first trimester B. early second trimester (14-21) C. late second trimester (22-28) D. third trimester |
D- the highest concentration of adult hemoglobin is near term, however, fetal hemoglobin makes up the majority of circulating hemoglobin (70%)
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During which trimester is the amniotic fluid volume derived from transudation?
A. first trimester B. early second trimester (14-21) C. late second trimester (22-28) D. third trimester |
A- amniotic fluid is transudative during early pregnancy, in the second trimester, the lung and kidneys both contribute to amniotic fluid volume
The contribution of the kidney steadily increases until it is the major contributor of amniotic fluid volume by the end of the second trimester and in the third trimester |
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During which trimester is there significant amniotic fluid volume contribution from the lung?
A. first trimester B. early second trimester (14-21) C. late second trimester (22-28) D. third trimester |
B. early second trimester- amniotic fluid is transudative during early pregnancy, in the second trimester, the lung and kidneys both contribute to amniotic fluid volume
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During what trimester are red blood cells produced by the spleen?
A. first trimester B. early second trimester (14-21) C. late second trimester (22-28) D. third trimester |
A. first trimester
Hematopoeisis occurs in the yolk sac in the second week of gestation, in the liver and spleen in the fifth week, and in the bone marrow by the 11th week |
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During what trimester are thyroxine levels first detectable in serum?
A. first trimester B. early second trimester (14-21) C. late second trimester (22-28) D. third trimester |
A. first trimester
thyroid hormones are detectable in the serum near the end of the first trimester. |
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23 year old primigravida woman just delivered an infant weighing 4350g by spontaneous vaginal delivery. After 5 minutes of gentle traction on the umbilical cord, you deliver the placenta, which appears to be intact. You begin massaging the uterine fundus and ask the nurse to run 20units of oxytocin in 1000mL of lactated Ringer's solutions as fast as possible. After careful inspection of the genital tract, you notice a second degree laceration and a 2 cm left lateral vaginal wall laceration, which you attempt to repair. Suturing is difficult because of brisk bleeding from above the site of laceration. Physical examination reveals a soft, boggy uterine fundus. Her vitals are: T= 98.9, BP= 164/92, P= 130, R= 18. Which is the next best step in management?
A. Oxytocin 10 U direct IV infusion B. Methylergonovine 0.2mg IM C. Prostaglandin F 0.25mg IM D. Manual exploration E. Curettage |
C. prostaglandin
uterine atony is the most common cause of postpartum hemorrhage. Because massage and dilute oxytocin have not been successful in ceasing her bleeding (the uterus is still soft and boggy), the next best step is to add another uterotonic agent. Methylergonovine is CI because this patient is hypertensive despite blood loss. The next best agent is prostaglandin. oxytocin would cause hypotension manual exploration would be ok if you suspected a laceration cutterage should be used if you suspect retained products of conception |
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40 hours ago, a 19 year old primagravida delivered a viable female weighing 3600g. APGARs were 9 and 9 at 1 and 5 minutes. The patient is breastfeeding and reports minimal lochia (post partum vaginal discharge). Review of her records show that her membranes were ruptured 7 hours before delivery. Her vitals before discharge were: T=100.8, P=105, BP=110/70, R=16. Her exam is remarkable for uterine tenderness, nonerythematous, nontender firm breasts and nontender calves. What is the best initial step before treatment with antibiotics?
A. urinalysis and culture B. genital tract culture C. blood culture D. incentive spirometry E. uterine curettage |
A. urinalysis and culture
The postpartum bladder is prone to infection d/t incompletely emptying resulting in residual urine, overdistention and stasis. |
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27 year old G2P1 presents for first prenatal visit. She reports regular cycles every 35 days. She has not used any contraceptive pills in the last 7 months. the first day of her last menstrual period was 04/01/2007 and the last day was 04/05/2007. She always bleeds for 4-5 days. What is the best estimate of her due date?
Just calculate it. |
January 15th, 2008
GOTCHA. Naegele's rule is based on a 28 days cycle. Because this patient has 35 days cycles and becaseu the luteal phase of the menstrual cycle is always constant (14 days), ovulation occurred on day 21 rather than day 14. |
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16 year old primigravida presents with abdominal pain. Her pain is constant and located in both the RLQ and LLQ. There is no radiation and no associated symptoms aside from constipation. The patient ate lunch a few hours ago without any problems. Vitals are: T= 97.8, BP= 108/74, P=96, R=14. Physical exam reveals tenderness in lower abdomen, but no rebound tenderness or CVA tenderness. Cervix is closed and uneffaced, the fetal vertex is high.
Urinalysis reveals +1 protein, 0 leukocytes, 0 nitrites, 0 bacteria, and 0-1 blood. Amylase, lipase, and liver enzymes are within the normal range except for elevated alkaline phosphatase. Her CBC is within normal range except for a WBC of 14,000. Which of the following is the best explanation for her abdominal pain? A. Braxton Hicks B. Round ligament pain C. UTI D. Uterine leiomyoma E. Liver disease |
B. Round ligament pain is common during the second trimester. It results from stretching of the round ligaments that are attached to the top of the uterus on each side and the corresponding lateral pelvic wall.
Braxton Hicks occur later in pregnancy Uterine leiomyoma can generate severe pain, but not usually bilaterally |
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20 year old presents in labor. She has not had any prenatal care. On examination of her cervix, you palpate a bulging membrane but no fetal parts. The cervix is 4 cm dilated. US demonstrates that the fetal head is in the fundus, the fetal spine is parallel to the mother's spine, and the knees and hips are flexed. Both arms are flexes at the elbows. Which of the following is the best description of the fetal lie?
A. Complete breech B. Incomplete breech C. Frank breech D. Vertex E. Longitudinal |
A. complete breech
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Know how to document appropriate gestations.
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PLEASE :)
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34 year old G2P1 at 32 weeks gestation presents to the office. She delivered her daughter vaginally at 39 weeks without complications. Her past history is unremarkable, and her current pregnancy has been uncomplicated other than occasional Braxton Hicks and increasing vaginal discharge that is nonpruritic, is the same color as her cervical mucus and has been present during most of her pregnancy. Her BP is 108/73, T= 96.8, fundus measures at 33 weeks, she is 5'4'', prepregnancy weight was 120 and now she weighs 135. She is rubella nonimmune, hep B negative, O+/antibody -, venereal disease nonreactive, gonorrhea/chlamydia negative. What is the next best step in management?
A. rubella antibody test B. 50g glucose tolerance test C. 300 anti-D immune globulin D. follow up in 2 weeks E. council about weight gain |
D. follow up in 2 weeks
by 32 weeks she should have already had a glucose test |
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28 year old G3P2 at 5 weeks presents to the office to start care. Her first pregnancy resulted in vag delivery of female weighing 3900g at term. Her daughter has a bilateral hearing deficit. her second pregnancy was a c section of a male weighing 2900g at 34 weeks because of PIH. Her son had a mild myelomeningocele. She tells you she is a lacto-ovo vegitarian. What is the most appropriate advice?
A. supplement your diet with iron B. supplement your diet with vit B12 C. increase folic acid intake D. eat lots of leafy, green veggies E. increase your calcium to 1200mg/day |
c. increase folic acid to 4mg/day because she has a history of delivering a child with a neural tube defect
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Aside from the fetus, what is the largest contributor to weight gain during pregnancy?
A. blood volume B. uterus C. placenta D. amniotic fluid E. breasts |
top four contributors are:
1. fetus (7.5lbs) 2. blood volume (3.5lbs) 3. uterus and lower extremity edema (2.5lbs) 4. amniotic fluid (2lbs) 5. placenta (1.5lbs) 6. breasts (1lb) BOOOOOOOOO |
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24 year old G2P1 at 27 weeks presents for routine prenatal care. She reports plenty of fetal movement and denies spotting or contractions. She does report increasing vaginal discharge that is white to yellow and has a distinct odor. Her temp is 98.2 and her BP is 100/60. The fundus measures 28cm above the symphysis pubis. her last pregnancy was uncomplicated. NKDA. PMHx is asthma. On exam you notice homogenous, adherent, white yellow discharge in the posterior fornix and the cervix, but the mucosa does not appear inflamed. pH is 5.5. Wet mount shows 30% clue cells. KOH prep has a strong order. What is the diagnosis and treatment?
A. normal discharge, follow up B. trichomonas, metronidazole C. bacterial vaginosis, clindamycin D. chlamydia, erythromycin E. candida, fluconazole |
C. bacterial vaginosis, clindamycin
pH<4.5, more than 15% clue cells, positive whiff test treated with metronidazole (first choice) or clindamycin |
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39 year old G3P3 is comtemplating pregnancy. She delivered three healthy boys at 17, 23 amd 27. Her first pregnancy was complicated by low birth weight and she suffered a third degree laceration after extension of a midline episiotomy after her third. She has asthma. What is she at highest risk for in her subsequent pregnancy?
A. asthma exacerbation B. fourth degree lacerationr C. low birth weight D. twins E. uterine dysfunction |
D. twins
age over 35 is a risk factor for multiple gestation asthma is unpredictable, teens are at risk for low birth weight and uterine dysfunction |
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34 year old primiparous woman is seeing you because she wants another pregnancy. She is worried because of her first pregnancy. At 32 years old, she delivered a Down Syndrome baby. During that gestation, serum screen for aneuploidy was not performed. Had a second trimester screen been performed, what would the screen have read for:
MSAFP, estriol, hCG, and inhibin A |
Down syndrome screen will show:
low MSAFP low estriol high hCG high inhibin A 80% of down syndrome can be detected with this |
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28 year old G6P1 comes in because of a positive home pregnancy test. Her LMP was 40 days ago. She had regular, 28 day cycles and her periods last 3-4 days. She delivered a preterm infant with her first pregnancy at 17 years old. Since, she has had three miscarriages and one ectopic. She had chlamydia in her teens but was treated. What is the most important initial step in management?
A. qualitative serum hCG B. quadruple screen (MSAFP, estriol, hCG, inhibin A) C. anticardiolipin antibodies D. chlamydia antibody E. transvag US |
E. transvag US--> history of ectopic and PID (chlamydia)
qualitative serum hCG will just confirm that the patient is pregnant, given that the patient has had a positive home preg test, a urin hCG is ok quad screen is not done before 16 weeks |
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33 year old G3P2 at 32 weeks presents for routine prenatal care. She delivered her first baby by c section d/t abnormal fetal heart pattern. Her second baby was an elective c section. Her records show that she had a Pfannenstiel skin incision and a low classical incision of the uterus. Now she wants a vaginal deliver. What do you say?
A. Vag delivery not recommended b/c risk of uterine rupture is 8% B. vag delivery is recommended because risk of uterine rupture is 1% C. vag delivery is not contraindicated with a history of two previous c sections D. vag delivery is possible, but risk of rupture is 4% E. vag delivery is possible but risk of rupture is 8% |
A. vag delivery is not recommended because of risk or uterine rupture up to 8%
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41 year old G8P4 at 18 weeks presents for her first prenatal visit. She had three abortions as a teen. She has 4 healthy kids now-- the first two delivered at 32 weeks and the last two delivered at 37 weeks. PMHx is significant for 2 episodes of pyelonephritis with her first two pregnancies as well as a bicornuate uterus. What in her history puts her at greatest risk for preterm delivery?
A. age B. delivery history C. abortions D. pyelonephritis E. uterine anomaly |
B. history
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25 year old G2P1 at 8 weeks presents to high risk clinic. Her first pregnancy was the delivery of a premature infant with respiratory problems. Her PMHx is remarkable for asthma (20 exacerbations/week) for which she uses albuterol and stroids. She has DM II which was treated with oral hypoglycemics before pregnancy. She tells you she got hep C a few year ago because she was a heroin addict. She is 5'5'' and 90#. Her BP is 180/98 and urine dipstick is negative. Which predisposes her to delivery of an infant with congenital anomalies?
A. weight B. liver disease C. diabetes D. hypertension E. IV drug history |
C. diabetes
pregestation diabetes increases the risk of birth defects by a factor of 3- anomalies of the heart and CNS are the most common |
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How will the following markers look in Down Syndrome?
AFP, hCG, estriol, inhibin A |
decreased AFP
increased hCG decreased estriol increased inhibin A |
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Which of the following cannot be detected on a second trimester US exam?
A. anencephaly B. renal agenesis C. tay sachs disease D. two vessel cord E. tetralogy of fallot |
tay sachs
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32 year old G1P1 comes in for genetic counseling. Her first child was born with sickle cell. She has since remarried and is requesting prenatal testing. Which is appropriate to offer?
A. Percutaneous umbilical blood sampling at the appropriate gestational age B. fetal chromosome analysis C. maternal hemoglobin electrophoresis D. paternal hemoglobin electrophoresis E. multiple markers screening |
D. paternal hemoglobin electrophoresis
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Which procedure poses the lowest risk for fetal loss?
A. chorionic villus sampling B. fetal echo C. percutaneous umbilical blood sampling D. fetal biopsy E. amniocentesis |
fetal echo
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Which is NOT an indication for prenatal diagnosis?
A. paternal age over 45 B. elevated MSAFP C. previous child with CF D. maternal VSD E. omphalocele detected on second trimester US |
paternal age 45
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23 year old woman in ER for a superficial gunshot wound to the wrist tested positive on her hCG screen. Her cycles have always been regular and occur every 28 days and are 4 days in duration. She believes she is on day 23 of her current cycle. No PMHx, no skoking or alcohol. She does take 20,000IH of vitamin A daily. Which does of vitamin A has teratogenicity been noted?
A. 5000 B. 8000 C. 10,000 D. 12,000 E. 20,000 |
B. 8,000
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28 year old G2P1 at 11 weeks comes in. She has a respiratory disease that requires frequent chest x rays. You add it up and she has had 260mrad to her fetus. What is the outcome of the pregnancy?
A. no adverse outcome B. growth retardation C. abortion D. bone marrow suppresssion E. MRa |
A. no adverse effect
expuosure of 5 rad or less has not been associated with adverse outcomes |
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28 year old biddie tested positive on a home pregnancy test. Her LMP was 36 days ago. Her periods usually occur every 30 days. Her PMHx is unremarkable and she denies tobacco, alcohol or drugs. Her only concern is that 3 weeks ago she got a rubella vaccine and was told by her doctor not to get pregnant for the next month. What is the best advice?
A. schedule elective termination ASAP B. option of therapeutic abortion within the first trimester C. rubella vaccine is not harmful to the fetus D. pregnancy outcome is favorable even after exposure to the vaccine E. live viral vaccines are associated with a fourfold increased risk of malformation |
D. still ok
even if known teratogenic agents are inadvertently taken during pregnancy, the outcome is still ok |
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19 year old G1P0 presents at 7 weeks. You educate her about nutrition, exercise and perform an in office transvaginal US to get the fetal age. You order routine labs too. She likes getting in hot tubs several times a day. What should you tell her?
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Sustained maternal hyperthermia (over 102) for more than 24 hours during the first trimester is associated with growth restriction and CNS defects, such as microcephaly, anencephaly and mental deficiency.
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Which teratogenic agent causes... persistent patent ductus arteriosus?
A. rubella B. parvovirus C. herpes simplex D. varicella zoster E. mumps |
A. rubella
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Which causes endocardial fibroelastosis?
A. rubella B. parvovirus C. herpes simplex D. varicella zoster E. mumps |
E. mumps
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Which causes a triad of heart, eye and ear defects?
A. rubella B. parvovirus C. herpes simplex D. varicella zoster E. mumps |
A. rubella
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Which causes skin scarring and shortened limbs?
A. rubella B. parvovirus C. herpes simplex D. varicella zoster E. mumps |
D. varicella
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Which causes aplastic anemia?
A. rubella B. parvovirus C. herpes simplex D. varicella zoster E. mumps |
B. parvovirus
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Exposure to how many rad can cause some adverse fetal effects?
3 6 10 30 50 |
10-25 rad have adverse fetal effects
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After what week, exposure to radioactive iodine may have adverse effects on fetal thyroid development?
3 6 10 30 50 |
C. 10
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Baseline risk of major congenital anomaly is...
3 6 10 30 50 |
A. 3
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Intrauterine fetal growth retardation is increased how many times in excessive drinkers?
3 6 10 30 50 |
A. 3 (really 2.7 times)
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Infants born to epileptic mothers have what percent incidence of congenital abnormalities?
3 6 10 30 50 |
B. 6
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The rate of congenital anomalies in pregnant women taking antipsychotic medication is...
3 6 10 30 50 |
B. 6
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18 year old student drinks once or twice a week. Lately she has been drinking more than 10 mixed drinks each time she goes out. Even though she gets severe hangovers, she doesn't believe that it will harm her. She is an average student and keeps a part time job. Her friends like her. She doesn't crave alcohol during the day, but now has to drink 6 drinks to feel the same way she did before when she only needed 4 drinks. This is:
A. use B. abuse C. tolerance D. dependence E. withdrawal |
B. abuse-- she still drinks even though she has severe effects (hangover)
apparently tolerance isn't a term they use |
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30 year old G2P1 at 8 weeks like to drink one glass of red wine a night. She drank the same amount with her last pregnancy and had a healthy baby. On ultrasound at 18 weeks, the ultrasonographer should pay close attention to the anatomy of the baby's:
A. bones B. brain C. heart D. kidneys E. vertebrae |
C. heart- OH use in first trimester has been associated with VSD
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20 year old G4P3 presents at 22 weeks for routine prenatal care. All of her previous pregnancies were complicated by preterm labor and delivery of small infants with respiraotry distress. She has a history of an inferiolateral MI this past year. Vitals are: T=99, BP= 170/96, P=135, R=18. The rest of her exam is normal other than what she describes as 'stretch marks' on her antecubital fossa. Which obstetric complication is most likely to occur during this pregnancy?
A. cerebral infarction B. chorioanmionitis C. placenta previa D. placental abruption E. seizure |
D. placental abruption
Her high BP, MI and 'stretch marks' (ie track marks) on her arm make you suspect drug abuse it's probably coke |
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25 year old G1P0 at 13 weeks presents for care. She says her baby moves frequently and keeps her up at night. She also reports increasing vaginal discharge that is odorless and asymptomatic. On exam you smell alcohol on her breath, she fails the finger to nose test. What is the initial best step?
A. alcohol and drug screen B. prescribe metronidazole C. refer her to a social worker D. confront her about your findings E. see her in 4 weeks |
D. confront her
... and then beat her into oblivion for drinking while she is preggo |
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35 year old G3P2 at 20 weeks is seeing you for a prenatal visit. She has chronic HTN and history of cholecystectomy. NKDA. She is an attorney who smokes marijuana several times a week for relaxation and says that she has read reports that she will have no adverse effect. Vitals are T=97.9, BP=108/68, P=100, R=16. Doppler shows fetal heart rate 156. What is the best course of action?
A. educate her about the delivery of a small infant B. refuse to see her if she doesn't stop smoking C. refer her to a social worker D. acknowledge that she is correct about no increased risk of anomalities E. see her back at 24 weeks |
A. educate her
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25 year old G2P1 at 36 weeks and 4 days with a hx of prior c section presents with abdominal pain and vaginal bleeding. She admits to using cocaine. Why is she bleeding?
A. trauma B. cervical polyp C. placenta previa D. placenta abruptio E. uterine rupture |
D. placenta abruptio
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39 year old G5P4 presents at 38 weeks with severe HA, abdominal pain and vaginal bleeding. PMHx is significant for emergent c section in the setting of placental abruption in her last pregnancy. She has chronic hypertension and uses tobacco. Her vitals are P=105, BP= 180/105. Her exam is significant for RUQ pain and a tender uterus. Her urinalysis shows 3+ protein. The following are all risk factors for placental abruption except:
A. hypertension B. hx of previous placental abruption C. increased maternal age D. hx of previous c section E. multiparity |
D. hx of previous c section
tobacco, prior hx, multiparity and HTN are all risk factors |
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20 year old G1P0 at 28 weeks complains of vaginal bleeding and back pain. She denies sexual intercourse within the last 48 hours. She denies trauma. On ultrasound, you see the fetus is in a cephalic presentation, amniotic fluid index of 10, and an anterior-fundal placenta. Fetal monitor shows coupled contractions. Fetal heart rate is 130. Her vitals are: T=98.6, P=90, BP=110/60, R=16. Exam reveals 100mL in the vaginal vault. Her cervix is closed. Which med would you defnintely administer?
A. rhoGAM B. terbutaline C. oxytocin D. betamethasone E. indocin |
D. betamethasone
this is placental abruption. the bleeding is significant, the fetus is preterm, administration of betamethasone to decrease complications of prematurity should delivery occur would be appropriate. |
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34 year old G2P1 at 34 weeks and 2 days presents reporting painless vaginal bleeding. On US you note the placenta completely overlying the internal os, a fetus in cephalic presentation and amniotic fluid index of 14. The cervix is closed on exam. Her BP=110/78 and her P=106. Fetal monitoring shows one uterine contraction every 30 minutes. What is the next best step?
A. magnesium sulfate B. hospitalization C. vag delivery D. c section E. dexamethasone |
B. hospitalization- expectant management is best if fetus is preterm and can benefit from further development
dexamethasone for advancement of fetal lungs is only useful between 24-34 weeks |
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28 year old G3P1 at 37 weeks reports for a scheduled c section and cesarean hysterectomy. She has a hx of two previous low transverse c sections. The first was because the fetus was in distress, and the second was elective. Her current pregnancy has been complicated with complete placenta previa. Delivery by low transverse cesarean is complicated by hemorrhage and hypotension. Patient recieves 20 unties of packed red blood cells. Which organ is most likely to malfunction?
A. adrenal cortex B. hypothalamus C. kidney D. liver E. heart |
C. kidney-- after hemorrhage, renal damage in the form of acute tubular necrosis is most likely to occur
pt also at risk for Sheehan syndrome (pituitary necrosis) |
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26 year old G2P1 at 39 weeks is admitted to the hospital for ruptured membranes. Her cervix is 5cm and 100% effaced and the fetal vertex is at +1 station. Fetal monitoring shows 5 contractions in 10 minutes, and each contraction produces 50mmHg or pressure. There hours later, her cervix is still 5cm dilated, 100% effaced and fetal position is at +1. What is the next step?
A. augmentation with oxytocin B. c section C. vacuum delivery D. magnesium sulfate E. methergine |
B. c section- patient has had arrest of dilation (no change in 2 hours)
oxytocin is not needed because she has adequate contraction frequency (every 2-3 minutes) and intensity not a candidate for vacuum (the cervix must be completely dilated and station at least 2+) |
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22 year old G1P0 at 40 weeks presents with regular contractions for the last 2 hours. She denies loss of fluid, and has good fetal movement. Her cervix is dilated 2cm and is 50% effaced and fetal vertex is at 0 station. Monitoring strip shows regular uterine contractions every 2-3 minutes. Fetal HR is 154 without decelerations and is reactive. What is the next best step?
A. c section B. oxytocin C. fundal massage D. walk for 1-2 hours and then check her cervix E meperidine |
D. walk!
patient is in the first stage (latent stage) of labor by having the patient walk and then return to check her cervix, you are able to diagnose labor if it changes |
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29 year old G2P1 at 32 weeks presents reporting flank pain, fever, chills and cramping. She is having contractions every 3-4 minutes, and the fetal HR is 180. She cervix is dilated 3 cm and is 100% effaced, and you see that the fetal head is floating. From urinalysis, you conclude she has pyelonephritis and admit her to the hospital for IV antibiotics, magnesium sulfate to slow down contractions and steroids. Several hours later she starts having trouble breathing: T=102, BP=110/78, P=105, R=28 and O2 sats are 95%. Exam shows that she is tachycardic but without murmurs. You hear bilateral rales over the lung bases. Abdomen is soft and nontender. She still has CVA tenderness. Which is the most likely diagnosis?
A. complication of pyelonephritis B. CHF C. PE D. pulmonary edema E. respiratory muscle paralysis |
F. pulmonary edema
she was give magnesium sulfate (known to cause pulmonary edema as a complication), she has rales because of exudation of fluid into the alveoli |
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24 year old G1P0 at 39 weeks is crowning. Fetal head is not emerging from vagina after 2 pushes. You palpate a thick hymenal ring at the introitus. Fetal monitoring strip shows bradycardia after the third push, so you perform a 3cm episiotomy that extends through hymenal ring and vagina and ends laterally in the perineum. What is the advantage of this type of episiotomy?
A. clean surgical incision B. avoids 4th degree laceration C. less dyspareunia D. common used when distance between posterior introitus and anus is large E. easier to repair |
B. avoids fourth degree laceration
median episiotomy is easier to repair, has less blood loss, causes less dyspareunia, heals better and has better anatomic results |
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What are the 7 cardinal movements of labor?
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Engagement
Descent (this is the first requirement) Flexion Internal rotation Extension Rotation (external) Expulsion |
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25 year old G1P0 at 39 weeks has been in labor for several hours. Her cervix is dilated 6cm and 80% effaced, and fetal vertex is at 0 station. Membranes have been ruptured for 20 hours and her labor is being augmented with oxytocin. the intrauterine pressure catheter detects contractions every 1-2 minutes at 80mmHg of pressure and lasting 2 minutes. Fetal heart rate is 90bmp for the last 2 minutes (30 minutes ago it was 140). What is the next best step?
A. penicillin B. c section C. left lateral position D. discontinue oxytocin E. anmioinfusion |
D. discontinue oxytocin
we are describing hyperstimulation of the uterus caused by excessive oxytocin stimulation, which has caused bradycardia in the fetus no level of oxytocin is predictive of whether is will cause hyperstimulation normal labor contractions last about 1 minute, produce 50mmHg and occur every 2-3 minutes |
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27 year old G1P0 at 40 weeks and 3 days is in the middle of the first stage of labor. Her cervix is 4cm and an epidural is placed. Prior to the epidural, she gets 500mL of Ringer's to prehydrate her, and augmentation with oxytocin is begun. Her vitals are: T=99, BP=110/74, P=102, R=18. Fetal HR is 142 with three accelerations every 20 minutes. She is contracting every 3 minutes.
After epidural, fetal HR drops to 130 and no accelerations are seen. Fetal HR shows a gradual decline in the middle of each contraction to 115 and then returns to 130. She has contractions every 2-3 minutes now and her vitals are: T=99, BP=78/56, P=115, R=18. What is the next best step? A. tylenol B. penicillin C. IV hydration D. ephedrine E. discontinue oxytocin |
D. ephedrine
one complication of an epidural is hypotension, the epidural blocks the sympathetic discharge to vessels walls and vasoconstriction is inhibited, this causes blood to pool in dependent areas of the body, decreasing venous return to the heart --> cardiac output decreases and there is decreased uteroplacental circulation to avoid hypotension, they should be hydrated first, but since she is already prehydrated, ephedrine is the next best |
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22 year old G2P1 at 41 weeks is laboring. Her cervix is dilated to 8cm and 100% effaced and fetal vertex is at +1 station. Membranes have been ruptured over 24 hours and labor is being augmented with oxytocin. Amnioinfusion is running because of 3-4+ meconium. Fetal heart rate is 138 with reduced short term variability and variable decelerations.
Now, monitor shows 6 contractions in a 10 minute period with a pressure of 70mmHg, and fetal heart rate is now 70 for more than 3 minutes. She is placed in left lateral position, oxytocin infusion is stopped, started on O2 and her IV fluid rate is increased. Fetal HR is now 98. What next? A. c section B. vacuum delivery C. ephedrine D. knee chest position E. terbutaline |
E. terbutaline- she has uterine hyperstimulation
normal labor has contractions every 2-3 minutes, lasting 45sec-1min and intensity of 50mmHg Since oxytocin has already been stopped, but the fetal heart rate has not come back up, you know that the oxytocin is still in her system you must reverse the effects with terbutaline (tocolytic) before you can take her to get a c section |
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19 year old G1P0 at 38 weeks is in active labor. Her cervix is 5 cm and the fetal vertex is at +1 station. Contractions are every 2-3 minutes, lasting 1 minute and producing 50mmHg pressure. The fetal HR is 140 with randome decelerations to 70 that return to baseline in 60-80 seconds. When this type of deceleration occurs, what is teh best description of the initial acid base status of the fetus?
A. respiratory acidosis B. metabolic acidosis C. uteroplacental insufficiency D. asphyxia E. increased PCO2 |
A. respiratory acidosis d/t severe variable deceleration
as the umbilical cord is compressed, decreased perfusion of teh fetal tissue occurs, this causes pressure of CO2 to increase and the pressure of O2 to decrease --> the increased PCO2 decreases the pH, resulting in acidemia |
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26 year old G2P1 at 20 weeks comes in. Her fundus measures 18 weeks and you are unable to hear fetal heart tone by doppler. You do an US and confirm lack of fetal heart activity and lack of fetal movement. Her last pregnancy was complicated by severe preeclampsia at 34 weeks and she was forced to deliver preterm. She tells you she had one episode of spotting 4 weeks ago but did not have cramping nor pass any clots or tissue. What is the diagnosis?
A. threatened abortion B. fetal demise C. incomplete abortion D. spontaneous abortion E. missed abortion |
E. missed abortion- death of fetus less than 23 weeks
fetal demise is a type of missed abortion that occurs after 23 weeks (when it is viable) |
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What is the most common cause of first trimester abortions?
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Trisomy
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30 year old G4P3 at 12 weeks comes in. Her first pregnancy was vaginal, her second was a c section with a low trasverse incision of the uterus for breech presentation and her third pregnancy was a 'natural' birth. What advice should you give about vaginal birth after c section (VBAC)?
A. not a candidate for VABC B. excellent candidate for VABC C. average candidate for VABC D. must have a c section E. risk of uterine rupture is 1 in 80 |
B. excellent candidate for VABC-- she has already had one successful vag delivery since the c section and the c section was performed for a 'nonrecurring' reason (breech), and she only had 1 c section
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G2P0 woman has been in labor for the past 24 hours. Her membranes have been ruptured for 17 hours, her cervix is dilated 10cm and is 100% effaced. Fetal vertex has reached the pelvic floor and was in left occipital anterior position. She has an epidural. now the vertex has reached +2 station. Given her protracted second stage of labor you perform a forceps delivery. What is not necessary prior to proceeding?
A. adequate anesthesia B. completely dilated cervix C. ruptured membranes D. an additional OB in the room E. confirmation of fetal head position |
D. additional OB
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What is the risk of uterine perforation after dilation and evacuation (D&E)?
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0-10%
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What is the risk of endomyometritis after c section?
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35-45%
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24 year old is at 20 weeks. Her PMHx is notable for mitral stenosis secondary to rheumatic heart disease as a child. What places her at risk for the development of heart failure during her pregnancy?
A. increase in minute ventilation B. increase in stroke volume C. increase in uterine size D. increase in renal plasma flow E. increase in red cell mass |
B. stroke volume
during pregnancy, cardiac output increases as a result of increase of stroke volume and heart rate |
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A woman at 40 weeks is schedule for MRI to address placenta accreta. The radiologist is unable to complete the study d/t nausea whenever the patient is supine. What do you recommend?
A. Antiemetic meds B. fasting prior to the study C. IV fluid loading D. tilting patient to the left E. supplemental oxygen |
D. tilt patient to left- 15% of patients get nauseated when supine, the gravid uterus compresses the vena cava and decreases venous return, this decreases cardiac preload and cardiac output
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24 year old with severe preeclampsia requires urgent c section for nonreassuring fetal heart rate. Which maneuver will increase the safety for airway management for this patient?
A. place nasogastric tube prior tp anesthetic B. has small diameter endotracheal tubes available C. get an arterial blood gas prior to induction D. administer a bronchodilator prior to induction E. hydrate the patient with 2L crystalloid |
B. have small diameter tubes available-- airway edema occurs during pregnancy and may be worsened by preeclampisa
if intubation is hindered by the edema, a small diameter ET tube may allow for the securing the airway |
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With induction of anesthesia, there is a rapid decline of the O2 saturation in a 40 week gestation female undergoing c section. This decline is a result of a decrease in which lung volume?
A. dead space B. total lung C. tidal D. residual E. inspiratory reserve |
D. residual- pregnancy results in both residual and expiratory reserve volume
these volume compromise the functional residual capacity |
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The pain of the second stage of labor is conveyed by which nerve?
A. paracervical B. ilioinguinal C. pudendal D. genitofemoral E. iliohypogastric |
C. pudendal-- stretching and tearing of the fascia, skin and subcutaneous
this nerve is blocked by the obstetrician |
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In a patient who complains of tinnitus and rapid heart rate after her injection of 3mL of lidocaine 1.5% with 1:200,000 epinephrine, what is the etiology of her symptoms?
A. anaphylaxis B. intravascular injection C. Intrathecal injection D. eclampsia E. anxiety |
B. intravascular injection- these symptoms are classic for this. The tinnitus results from iv lidocaine and the rapid heart rate from iv epinephrine
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24 year old at 40 weeks gestation is in active labor and requests an epidural analgesic. During placement, the dura is punctured. The patient is at increased risk for the development of which complication?
A. leg weakness B. backache C. headache D. hemorrhage E. dyspnea |
C. headache- postdural puncture headache is a bilateral headache that develops within 7 days after dural puncture and disappears 14 days after the puncture
it worsens within 15 minutes of assuming the upright position and improves within 30 minutes of laying down |
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21 year old in labor is considering epidural analgesia. Which is increased in patients with epidural analgesia?
A. prolonged labor B. c delivery C. impaired breast feeding D. neonatal depression E. cerebral palsy |
A. prolonged labor
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22 year old G1P0 at 15 weeks by her last menstrual period presents for an US to confirm her due date. Which measurement on the fetus is best at predicting the actual due date?
A. crown rump length B. biparietal diameter C. abdominal circumference D. femur length E. head circumference |
B. bipareital diameter
in teh second trimester (over 13 weeks), the most accurate is the BPD Crown rump is the most accurate in the first trimester |
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25 year old G3P0 at 42 weeks comes in. She has accurate dating and has been receiving twice weekly nonstress tests for the last week. Underdevelopment of which structure in the fetus may contribute to prolongation of this gestation?
A. cerebral cortex B. thalamus C. thymus D. adrenal cortex E. ovary |
D. fetal adrenal hypoplasia has been associated with prolongation of gestation, as well as anencephaly
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34 year old G3P1, abortion 1, at 42 weeks presents to the clinic. Her nonstress test is reactive and amniotic fluid volume is 8.5. Her cervix is 0.5cm dilated, 20% effaced, midposition and firm with fetal vertex at -4 station. Which of the following is the best next step?
A. oxytocin B. prostaglandin analog C. twice weekly nonstress test D. repeat modified biophysical profile E. artificial rupture of membranes |
B. prostaglandin analog- at 42 weeks of gestation, if the cervix remains unfavorable, prostaglandins will be administered to ripen the cervix for induction
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25 year old G3P2 comes to labor and delivery at 30 weeks with regular uterine contractions. Cervical exam shows 3cm of dilation and 80% effacement. The patient is given corticosteroids and tocolytics. The contractions persist even after administration of a second tocolytic agent and the obstetrician orders an amniocentesis. The amniotic fluid show bacteria on gram stain. the next best step is:
A. continue tocolytics until 48 hours B. discontinue tocolytic therapy C. send the fluid for lecithin to sphongomyelin ratio D. sent maternal serum for CBC E. administer the second dose of betamethasone 24 hours after first dose |
B. discontinue tocolytic therapy-
when tocolysis continues after 2 tocolytic agents, chorioamnionitis must be considered laboratory evidence of chorioamnionitis is a contraindication for tocolytics |
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28 year old G3P2 at 28 weeks has been in the hospital for several days because of preterm labor. Her cervix is dilated to 3cm and 100% effaced for which magnesium sulfate is started at 2.5g/hr after a bolus after 30 minutes. She also received antibiotics and steroids. Currently, she has 3-4 contractions per minute that she barely feels on 2g/hr. Treatment with magnesium sulfate is most likely to:
A. reduce rate of preterm birth B. reduce morbidity associated with preterm delivery C. reduce mortality associated with preterm delivery D. stop contractions E. delay delivery for 2 days |
E. delay delivery- treatment with tocolytic meds may not reduce the rate of preterm birth, but it may delay delivery for 48 hours and reduce associated complications
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22 year old G1P0 at 33 weeks comes in with cramping and back pain. she denies any fluid leaking. Speculum exam shows no pooling, and nitrazine paper stays yellow after contact with the secretions in the posterior fornix. Cultures are taken. Fetal heart rate is 155 and there are 3 uterine contractions per a 10 minute period. Her cervix changes from closed and 50% effaced to 2-3 cm and 80% effaced. the next best step in management is:
A. antibiotics B. MgSO4 C. terbutaline D. steroids and tocolytic therapy E. US |
D. steroids and tocolytic therapy- the patient is in preterm labor, tocolytic drugs may prolong pregnancy for 2-7 days, which allows for administration of steroids for lung maturity
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29 year old G2P1 at 30 weeks is in preterm labor. She has received a bolus of 6g MgSO4 over 30 minutes, and she has been placed on a maintenance rate of 4g/hr for the last 2 days to reduce her contraction pattern to one every 15 minutes. Vitals are: P=88, BP=90/50, R=9, O2 sats= 95%. Her deep tendon reflexes are 0 bilaterally. She has crackles in her lungs. The next best step in management is:
A. serum magnesium level B. calcium gluconate C. switch to terbutaline D. discontinue MgSO4 E. re evaluate her cervix |
D. discontinue MgSO4- she is becoming toxic, her reflexes are gone, she is lethargic and her respirations are slow.
calcium gluconate is given when magnesium levels are too high |
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24 year old G1P0 at 24 weeks by her LMP presents to the ER for vaginal bleeding. T=97, BP=135/88, P=105, R=16. Her fundus is below the umbilicus and there are no fetal heart tones on doppler. Speculum exam reveals blood coming from the undilated os. Her hCG is 85,000. You are waiting on an US to confirm molar pregnancy. What is the most likely explanation?
A. Mom 0 + dad Y B. Mom 0 + dad X C. Mom Y + dad X D. Mom X + dad X + dad X E. Mom Y + dad X + dad Y |
D. mom X + dad X + dad X
this is a partial or imcomplete mole because the uterus is small than dates and the hCG is lower than 100,000 In a partial mole, the ovum is normal and contributes only one of its chromosomes, the normal ovum is fertilized by two sperm --> triploid fetus |
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24 year old G1P0 at 24 weeks by her LMP presents to the ER for vaginal bleeding. T=97, BP=135/88, P=105, R=16. Her fundus is below the umbilicus and there are no fetal heart tones on doppler. Speculum exam reveals blood coming from the undilated os. Her hCG is 85,000. You are waiting on an US to confirm molar pregnancy. What will you most likely see on US?
A. fetus with biparietal diameter consistent with 22 weeks B. two vessel umbilical cord C. two separate placentas D. left ovary 6 cm and right ovary 3 cm on right E. left ovary 6cm and right ovary 6 cm |
B. two vessel umbilical cord
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33 year old G4P3 at 16 weeks presents complaining of vaginal bleeding. Her vitals are T=98.9, BP= 150/94, P=103. Fundal height measures 23cm. US shows uterus with a diffuse indistinct mass filling the endometrial cavity, and no fetal parts are seen. Dilation and suction is performed and 10 minutes afterwards she is put on an IV oxytocin drip. Complications in which organ is most likely to occur?
A. liver B. kidney C. vagina D. lung E. brain |
D. lung- respiratory distress is the most commonly complication, the lungs can be injured d/t embolic events from trophoblastic tissue
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27 year old nulliparous woman comes to the ER with hemoptysis. She had a spontaneous abortion 3 months ago. She has had intermittent vaginal spotting since the miscarriage. Her BP= 110/70, P=88, hemoglobin= 9.6mg/dL, hCG= 35,000. Her chest radiograph shows masses in the right middle lobe. Which is the best treatment option?
A. dilation and curettage B. hysterectomy C. methotrexate and leucovorin D. actinomycin D E. methotrexate, actinomycin and etoposide |
C. methotrexate and leucovorin- patietn has metastatic disease with a good prognosis (hCG <40,000)
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36 year old multiparous woman underwent hysterectomy d/t molar pregnancy. Other than treatment for gestational trophoblastic disease, she has no medical problems. She had an appendectomy 3 years ago. She is allergic to PCN and admits to drinking 3-4 alcoholic beverages/day. You get a hCG 2 days after the oberation. What is the next best step in management?
A. hCG in one week B. hCG in one month C. methotrexate D. levonorgesterel plus ethinyl estradiol E. chest radiograph in one month |
A. measure hCG in one week
the most important step of molar pregnancy is to ensure that the patient does not get pregnant within the next year because it would confound follow up with hCG levels must do 48 hour post hCG, weekly hCG until results are negative 3 times and then every month for 6 months |
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24 year old G1P0 comes in because every month since 19 she has have severe lower pelvic pain with her periods. The pain is similar to labor pains and it interferes with her work performance. The pain has also made her anxious and irritable. She has tried acetaminophen with little relief. She denies depression, change in sleep, energy or eating problems. Her PMHx is remarkable for mild asthma controlled with albuterol. She is sexually active, in a monogamous relationship and uses condoms. The next step:
A. ibuprofen B. norgestimate plus ethinyl estradiol C. fluoxetine D. calcium E. leuprolide |
A. ibuprofen- dysmenorrhea, use NSAIDs
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Multiple follicles develop with in vitro fertilization because:
A. in an IVF cycle LH is not needed for follicular development B. there is excess FSH available C. hCG is more potent than natural LH D. FSH induces LH release E. progesterone is not given until after the oocytes are retrieved |
B. there is excess FSH available- all the follicles are exposed to adequate stimulation to grow and develop
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Hormone X and Y are secreted in the follicular phase and are responsible for suppressing FSH in the late follicular phase prior to ovulation. Hormone Z is responsible for allowing the oocytes to progress through to metaphase II. What are the hormones X, Y, and Z?
A. estrogen, progesterone, LH B. estrogen, inhibin A, FSH C. estrogen, activin, FSH D. estrogen, inhibin A, LH E. estrogen, inhibin B, LH |
D. estrogen, inhibin A, LH
in the follicular phase estrogen and inhibin B both work to suppress FSH directly --> the negative feedback leads to less FSH to stimulated follicular development and as a result only one follicle becomes dominant |
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24 year old nulligravid presents to the office with amenorhhea for 4 months. She was started on birth control at the age of 18 for irregular periods. She stopped 4 months ago. Labs show hCG less than 5, prolactin =12, TSH=2.2, FSH=67, estradiol <30. Which is the most likely?
A. stress induced amenorrhea B. Swyer syndrome C. Turner syndrome D. androgen insensitivity syndrome E. mullerian anomaly |
C. Turner syndrome-
patient has hypergonadotrophic amenorrhea; not all patients with turner syndrome display the characteristic physical findings. |
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18 year old nulligravid female is seeing you because she has not had a period for the last 8 months. She is sexually active. She began her menses at age 13 and had irregular periods for the first 2 years and then became regular. She is 5'8'' and weighs 90#. Her vitals are: T=96.6, BP= 108/60, P= 52. Pelvic exam is unremarkable. The only other issue found on physical exam is the loss of erosion on the upper and lower incisors. She also has small scars on her hands. The most likely hormone abnormality is:
A. increased T4 B. decreased FSH C. increased TSH D. decreased cortisol E. increased prolactin |
B. decreased FSH- she is anorexic
patients with anorexia have decreased gonadotropins (LH, FSH), low estrogen, low free T3, normal T4, normal TSH and normal prolactin. Also have elevated cortisol (it is a 'stress' hormone) |
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Woman with amenorrhea presents for an appointment. She is 25, a bank executive that travels around the world and a marathon runner. What structure most likely accounts for her ammenorrhea?
A. hypothalamus B. pituitary C. ovaries D. uterus E. vagina |
A. hypothalamus-- any type of excessive stress in the form of lifestyle, exercise or major illness changes neurotransmitter function within the hypothalamus. Stress causes hypothalamic dysfunction resulting in changes in the GnRH pulse, which results in low levels of LH and FSH. With hypothalamic amenorrhea, the FSH may be low or normal as in this patient
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16 year old presents because she has never had a period. She is 5'7'', 125 pounds and is a good student. He has tanner stage 4 breasts development, axillary hair growth, and pubic hair growth onto her thighs. On speculum exam, you discover a short vagina that ends blindly. The diagnosis is:
A. androgen insensitivity syndrome B. Swyer syndrome C. 17 alpha hydroxylase deficiency D. Mayer Rokitansky Kuster Hauser Syndrome E. Kallmann syndrome |
D. Mayer Rokitansky Kuster Hauser syndrome- this is the most common disorder of the outflow tract and the second most common cuase of primary amenorrhea; patients have normal female karyotype and normal ovarian function, so growth and development is normal
the development of the uterus, cervix and vagina is abnormal, absent or short vagina, they lack a uterus and falllopian tubes or have rudimentary uterine cords that do not connect 33% association with urinary tract anomalies |
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21 year old nulliparous woman comes into your office reporting several years of irregular menses occurring only 4-5 times/year. On physical exam, you notice hair on her neck, chin, upper lip and lower abdomen. Lab workup of this patient should include all of the following except:
A. TSH B. serum testosterone C. 17 OH progesterone D. LH/FSH E. prolactin |
D. LH/FSH- the ratio is not necessary for diagnosis
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17 year old complains of increased hair growth over the past 6 months. Her menses have been irregular. Labs shows that she probably has PCOS. What is the best recommendation for treating excess hair growth?
A. combined hormonal contraceptive B. combined hormonal contraceptive and electrolysis C. antiandrogen and laser or electrolysis D. metformin and laser or electrolysis E. combined hormonal contraceptive, antiandrogen and laser or electrolysis |
E. combined hormonal contraceptive, antiandrogen and laser or electyrolysis- best tx for hirsutism is to blodk stimulus to hair growth and remove existing hair permanently
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Obese 38 year old comes into your office complaining of several episodes of irregular spotting in the past 6 months. She has a long history of irregular periods and was diagnosed with PCOS as a teen. She is not sexually active and has never been on hormonal contraception. She does not desire fertility at this time. the most important test to perform in this patient is:
A. 2 hour GTT B. glucose/insulin ration C. serum lipids D. endometrial biopsy E. pelvic US |
D. endometrial biopsy- patient is over 35 and has a long history of irregular menses is at increased risk for endometrial hyperplasia and endometrial cancer
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27 year old obese nulliparous woman has been on oral contraceptives since age 16 for irregular periods. She comes in because she has stopped taking her pill 6 months prior but has not had a period since stopping her pill. She and her husband would like to conceive, but she is worried her weight may be a problem. You counsel that:
A. her weight is not a problem B. if she lost weight, she may start to have periods on her own C. if she takes metformin, she will lose weight D. obesity if a problem and you would recommend gastric bypass E. a 25% weight reduction is necessary to improve insulin resistance |
B. a 7-10% reduction in weight is associated with resumption of menses and ovulation and improvement in insulin resistance and androgen levels
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a 32 year old G0 woman comes in with her husband because they want to conceive. She has had PCOS for 14 years and has been maintained on oral contraceptives and antiandrogens since then. She stopped them and started prenatal vitamins per your instruction 4 months ago and has not had a period since. Her pregnancy test is negative. AT this point, what do you recommend?
A. medroxyprogesterone acetate B. clomiphene citrate C. metformin D. gonadotrophins E. IVF |
B. clomiphene citrate- in PCOS, the most likely cause of inability to conceive is anovulation. 80% will ovulate on clomiphene
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33 year old G2P1, 1 spontaneous abortions, presents to the office reporting increasing dark hair growth on her chin, upper lip and lower abdomen. She denies changes in her voice, size of clitoris, reduction in breast size or acne. During her early teens, she had regular menstrual periods that lasted 4-5 days. Now she takes birth control to regulate her cycles. Her PMHx is significant for hep C, which she acquired from a blood transfusion to treat postpartum hemorrhage with her first pregnancy. the next best stop in management of hirsutism is:
A. depo B. flutamide C. spironolactone D. dexamethasone E. leuprolide |
C. spironolactone- the best complement to oral contraceptive pills in the treatment of hirsutism is spironolactone --> it binds to the androgen receptor, preventing the binding of DHT and inhibits hair growth
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23 year old G1P0 has irregular, unpredictable menstrual cycles every 30-90 days. She has acne on her face, back and several dark, coarse hairs on her chin and lower abdomen. The initial step in diagnosis of androgen excess is to measure which of the following?
A. androstenedione B. dehydroepiandrosterone sulfate C. LH and FSH D. 17 hydroxyprogesterone E. 5 alpha reductase |
D. 17 hydroxyprogesterone- the patient most likely has PCOS because she has menstrual irregularity and clinical evidence of hyperandrogenism, to confirm this 17 hydroxyprogesterone must be drawn
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22 year old female presents to office with severe hirsutism on her face. She is shaving daily and is very distressed. You diagnose PCOS after evaluation. You give her what advice for the best way to manage her hirsutism symptoms?
A. shaving is bad because it makes the hair grow faster B. she would be a good candidate for laser epilation C. medroxyprogesterone acetate is the best option D. combined hormonal contraception with spironolactone is the best option E. metformin therapy for PCOS is the best option |
D. combined hormonal contraception with spironolactone is the best option
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50 year old G3P2 with 1 spontaneous abortion presents with abnormal bleeding. Her menstrual cycles used to occur regularly every 30 days and last 3-4 days. She now has periods every 15-22 days and they last 6-7 days. ROS is negative and she specifically denies light headedness. Her bimanual exam reveals a slightly enlarged, regular contour, anteverted uterus that is nontender to palpation. The next best step is:
A. low dose contraceptive pills B. endometrial biopsy C. D&C D. endometrial ablation E. levonorgestrel IUD |
B. the risk of endometrial carcinoma increases with age and should be ruled out in patients with abnormal bleeding who are over 40
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14 year old nulligravid reports menstrual bleeding every 45-50 days and bleeding for 4 days. She experienced menarch at age 13. She is not sexually active. Her exam is unremarkable. The next best step in management is:
A. birth control B. reassurance C. NSAIDs D. hysteroscopy and D&C E. coagulation profile |
B. reassurance- periods will normalize after around 2 years
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32 year old G1P1 presents with bleeding between her periods and lengthening of time between her periods to more than 40 days. ROS is remarkable for a 70lb weight gain since her pregnancy 2 years ago. She denies any medical problems. She is 5'4'' and weights 230#. Exam is unremarkable. The most likely explanation for her bleeding is:
A. increased endogenous progesterone B. increased exogenous progesterone C. increased endogenous estrogen D. increased exogenous estrogen E. increased prolactin |
C. increased endogenous estrogen- patient is obese and therefore likely has increased endogenous production of estrogen from adipose tissue, which can lead to suppression of FSH and anovulation
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18 year old nulligravid girl presents to the ED because she passed out on the floor of her house and is covered in blood. She has been bleeding off and on for the past 5 months. Her BP= 98/48, P=120, RR=16 and T=96.2. Speculum exam reveals blood trickling from the cervical os. There are no lesions in the vagina or cervix. hCG is negative and her hemoglobin is 7g/dL. The next best step is:
A. depo B. oral conjugated estrogen C. IV estrogen D. low dose combination oral contraceptive pills E. GnRH agonist therapy |
D. low dose combo oral contraceptive pills
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38 year old presents with a 2 year history of heavy menses lasting 9 days with occasional episodes of soaking her clothes and bedsheets. Her periods occur every 32 days. She denies bleeding between menses. PMHx is notable for HTN. Next step should be:
A. obtain a coagulation profile B. obtain a pregnancy test C. perform an endometrial bx D. obtain a pelvic US E. obtain a TSH level |
D. obtain a pelvic US- history of regular cyclic menstrual flow, but with menorrhagia; regular flow does not suggest an ovulation disorder and the bleeding is most likely from a structural problem.
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25 year old G4P4 with hx of leiomyomas comes to ED with pelvic pressure. A pelvic US shows a 10cm left uterine mass that hsa teh echogenicity of a fibroid. Pressure from the fibroid may also cause:
A. leg ulcers B. peau d'orange C. superficial thrombophlebitis D. DVT of the leg E. varicose veins |
C. varicose veins- compression of pelvic vasculature from a markedly enlarged uterus may cause varicosities or edema
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30 year old G2P2 presents to you for her annual visit. You perform a Pap and a pelvic exam that reveals an enlarged, nontender, irregular uterus and no adenxal mass or tenderness. The most likely type of fibroid is:
A. anterior intramural fibroid (5cm) B. submucosal pedunculated fibroid (2cm) C. subserosal pedunculated fibroid (7cm) D. posterior intramural fibroid (5cm) E. intramural fibroid with a submucous component (5cm) |
C. subserosal pedunculated fibroid- these are usually asymptomatic
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22 year old G2P1 at 20 weeks presents to the ED with acute onset lower abdominal pain. She has a hx of fibroids and an unknown abdominal surgery. Vitals are: T=99, BP= 105/68, P=110, R=28. There is a linear 4cm scar in the right lower quadrant, bowel sounds are present and the abdomen is nontender except for a spot tenderness in the midline, between the umbilicus and the symphysis pubis. There is no rebound tenderness. No CVA tenderness. Fundus is 28cm above the symphisis pubis. Her WBC are elevated, urinalysis is normal, and lifer function tests are within normal range. the most likely diagnosis is:
A. leiomyomatous degeneration B. ovarian torsion C. cystitis D. preeclampsia E. appendicitis |
A. leiomyomatous degeneration- hx of fibroids
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27 year old G2P1 at 30 weeks presents to the clinic. 'Serosal fibroids' are listed under her problem list. Her fundus is 37 cm from the symphysis pubis. In discussing possible complications of a fibroid uterus during pregnancy, you mention she is at highest risk for:
A. preterm premature ROM B. placenta previa C. pregnancy induced hypertension D. breech presentation E. placental abruption |
D. breech presentation
in the third trimester, leiomyomas may be a factor in malpresentation, mechanical obstruction and uterine dystocia |
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49 year old G3P2 (1 spontaneous abortion), who has known myomatous uterus presents to you because of heavy bleeding during her periods and occasional spotting in between her periods. Her menses occurs every 5-6 weeks and lasts 6-10 days. It is associated with painful cramps. the next best step in management is:
A. GnRH agonist for 3 months B. GnRH agonist for 6 months and add back hormones for the last 3 months C. hysterectomy D. endometrial biopsy E. transvaginal US |
D. endometrial biopsy- you cannot assume that abnormal bleeding in a 49 year old is caused by leiomyomas b/c she has a myomatous uterus. the risk of other endometrial disease such as polyps, hyperplasia and carcinoma is significant and should be ruled out.
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34 year old G0 has been trying to get pregnant for 3 years. Her history is also significant for pelvic pain for several years and deep dyspareunia. On pelvic exam, you palpate a nodular, tender, uterosacral ligament, a retroverted buy normal sized uterus, and a right adenexal mass. US reveals a 6cm right complex ovarian mass. Her CA 125 is elevated. What is the next step?
A. expectant management B. GnRH agonist C. diagnostic laparoscopy D. laparoscopy with cystectomy E. laparoscopy and right oopherectomy |
D. laparoscopy with cystectomy
most likely dx is endometrioma of the right ovary |
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23 year oldG1P1 reports lower abdominal pain of 1 year. the pain is constant and and dull and worse with her periods. She has no significant PMHx and takes oral contraceptives. You perform a laparoscopy and find several deep, typical endometriotic lesions over the bladder and on both uterosacral ligaments and adjacent to both ovaries. All visible lesions are ablated using the laser. What is the next best step in managment?
A. oral contraceptive therapy B. GnRH agonist C. aromatase inhibitor added to oral contraceptive therapy D. total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) E. danazol |
A. oral contraceptive therapy
endometriosis is diagnosed and surgically treated at the time of the laparoscopy. medical management of the endometriosis is indicated at this point to help control the disease - oral contraceptive pills given continuously would be the best option The pt had significant pain on pills prior to surgery, but surgery treated the disease and therefore the symptoms may improve GnRH would be the next best thing if the sx didn't resolve |
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Which patient is most UNlikely to have to have endometriosis?
A. 19yo with cyclic pelvic pain and bicournuate uterus with a noncommunicating uterine horn B. 28yo with cyclic pelvic pain and who has a mother a sister wtih endometriosis C. 25yo with a hx of dyspareunia, painful nodular masses in the rectovaginal septum and a left adenexal mass D. 28yo with menorrhagia and a 4cm submucosal myoma E. 32yo with infertility and dysmenorrhea and a fixed and retroverted uterus on physical exam |
D. 28 year old with menorrhagia and 4cm submucosal myoma
patients with a Mullerian anomaly that blocks the egress of menses are at high risk. siblings with endometriosis are at increased risk of the disease (7%). Dyspareunia, rectovaginal noules and adnexal mass is highly suggestive of endometriosis. |
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Which blocks production of estrogen within the endometriosis implant?
A. aromatase inhibitor B. prostaglandins C. allen-master lesions D. pneumothorax E. powder burn lesions |
A. aromatase inhibitor
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Patient with red hemorrhagic vesicles and white lesion who has a pelvic peritoneal defect on laparoscopy?
A. aromatase inhibitor B. prostaglandins C. allen-master lesions D. pneumothorax E. powder burn lesions |
C. allen master lesions- defects with local scarring
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Reason why naproxen may alleviate pain symptoms in a patient with endometriosis.
A. aromatase inhibitor B. prostaglandins C. allen-master lesions D. pneumothorax E. powder burn lesions |
B. prostaglandins
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What is a complication of extraperitoneal endometriosis?
A. aromatase inhibitor B. prostaglandins C. allen-master lesions D. pneumothorax E. powder burn lesions |
D. pneumothorax- menstrual cycle related pneumothorax or catamenial pneumothorax is caused by endometriosis present within the pleura
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25 yo G1P0 is in the ER with low pelvic pain and spotting for 1 week. Her last normal period was 7 weeks ago. Serum hCG is 4000, transvaginal US performed which revealed no gestational sac in the endometrial cavity, no adnexal masses and no free fluid in the cul-de-sac. Next best step in management is:
A. repeat hCG in 2 days B. laparoscopy C. laparotomy D. methotrexate, dingle dose E. D&C |
E. D&C- when the hCG is above the discriminatory zone (usually 2000) and no pregnancy is seen on US, the pregnancy is either outside the uterus or is an abnormal intrauterine pregnancy, to distinguish between the two curettage should be performed
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28yo G2P1 + ectopic presents for annual exam. She wants another child. Her menstrual cycles are regular, occuring every 28 days. You tell her if she misses her period to come in immediately because:
A. given her history, she has a 33% change of delivering a live infant B. she needs a urine pregnancy test to rule out an ectopic C. her risk of recurrent ectopic is 15% D. her risk of recurrent ectopic is 30% E. she is at risk for PID |
D. risk of recurrent ectopic is 30%
note that pts with prior ectopic do have a 33% chance of delivering a live child, but this is not a reason for her to come back ASAP |
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23yo G3P1 + 1 ectopic comes in because she missed her period and has a sharp, intermittent pain in her left lower abdomen. Her ectopic was on the left side and was treated with methotrexate, several years after the vaginal delivery of her son. hCG is 10,500. On exam, her BP= 110/74, P=90, T=98.7. She is obese and lacks peritoneal signs, no masses are palpated. Transvag US in office shows no gestational sac and a 4.3cm mass in the left adnexa. What is the next best step?
A. laparoscopic salpingostomy B. laparoscopic salpingectomy C. methotrexate D. exploratory laparotomy E. repeat hCG in 2 days |
B. laparoscopic salpingectomy- the patient has an ectopic in the same tube she did before, so after two, she needs to remove the tube
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36 yo nulligravid woman is seeing you for her annual exam. PMHx is significant for pulmonary fibrosis. Within the past 3 years. All of the following are remarkable in her chart: bacterial vaginosis, candida, chronic endometritis, pyelonephritis, history of IUD removed 5 years ago and history of infertility for which she was treated with fertility drugs and IVF. She drinks 2-3 alcoholic beverages/day. She has a FH of colon cancer. Which places her at the greatest risk for ectopic pregnancy?
A. Age B. Pulmonary fibrosis C. Past IUD D. Infertility E. Chronic endometritis |
D. infertility is a risk factor for ectopic pregnancy; current IUD use (not past) is a risk factor
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24yo G3P1 + 1spontaneous abortion presents to ER with irregular vaginal bleeding. She is found to be pregnant and her hCG is 3500. She has a past medical history significant for DM and mild asthma. Her BP=103/68, P=88, T=98.8. Transvaginal US shows a uterus w/o a gestational sac and a 2cm right adnexal mass. Least invasive treatment of choice is:
A. Expectant management B. Methotrexate C. Laparoscopic salpingostomy D. Laparoscopic salpingectomy E. Laparotomy |
B. Methotrexate (there are no contraindications- hCG not high, less than 3cm mass, mild asthma and DM are not contraindications)
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25 year old G2P2 has been trying to get pregnant for 2 years. She had surgery for a ruptures appendix 5 years ago. Periods are regular and last 3-4 days. She denies smoking, drinking or drugs. Her husband is 28 and has a normal sperm count. What is the cause of infertility?
A. Ovulation B. Oocyte quality C. Tubal factor D. Uterine factor E. Male factor F. Unexplained |
C. tubal factor- adhesion from surgery on the fallopian tubes that prevents proper egg retrieval and transport
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29yo G5P1 plus 4 spontaneous abortions comes in because she cannot carry a successful pregnancy. She becomes pregnant easily but miscarries at 10-14 weeks. Her bimanual exam reveals an enlarged uterus. Her husband is healthy. What is the cause of infertility?
A. Ovulation B. Oocyte quality C. Tubal factor D. Uterine factor E. Male factor F. Unexplained |
D. uterine factor- submucosal fibroids in her uterus contributing to her miscarriages
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30 yo nulligravid female has been trying to get pregnant for 2 years. She has regular 30 days cycles and denies dysmenorrheal. Pelvic exam and labs are all normal. Ovulation is confirmed by midluteal phase progesterone level. Testing shows normal uterus and patent bilateral fallopian tubes. Husband is 31 with normal sperm counts. What is the cause of infertility?
A. Ovulation B. Oocyte quality C. Tubal factor D. Uterine factor E. Male factor F. Unexplained |
F.unexplained
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39yo G1P0 d/t spontaneous abortion presents with 2 years of infertility. She has regular 30 day menstrual cycles. You note an antral follicle count of four from the two ovaries. The hysterosalpinogram shows normal uterine cavity and bilateral tubal patency. Her husbands semen analysis is normal. What is the cause of infertility?
A. Ovulation B. Oocyte quality C. Tubal factor D. Uterine factor E. Male factor F. Unexplained |
B.oocyte quality- older patient has a low antral follicle count, decreased ovarian reserve
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27 year old G2P2 presents because she has not been able to get pregnant after reversal of her husband’s vasectomy. What is the cause of infertility?
A. Ovulation B. Oocyte quality C. Tubal factor D. Uterine factor E. Male factor F. Unexplained |
E.male factor
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22yo nulligravid woman and her husband have been trying to get pregnant for 18 months. Her periods are irregular. She gets 4-5 periods/year. She is 5’2’’ and 210 pounds. She reports hair on her chin. What is the cause of infertility?
A. Ovulation B. Oocyte quality C. Tubal factor D. Uterine factor E. Male factor F. Unexplained |
A. ovulation
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Among 1000 healthy, fertile couples, how many will become pregnant within 1 month with regular intercourse?
A. 15 B. 20 C. 35 D. 45 E. 85 |
B. 20
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26 yo nulligravid and her 26 year old husband come in because they cannot get pregnant. The woman has regular periods every 30 days that last 4days. Husband’s sperm count reveals volume of 2.5mL, total count less than 0.1x10^6 sperm/mL, 10% forward progression and 30% normal morphology. The next best step is:
A. Semen wash, intrauterine insemination B. IVF with intracytoplasmic sperm injection and embryo transfer C. Conventional IVF and embryo transfer D. Karyotype, FSH, testosterone, Y microdeletion testing |
D.karyotype, FSH, testosterone- need to work up oligospermia
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Patient with 3 miscarriages presents to your office. Lab eval has the following results:
Lupus anticoagulant screen negative, anticardiolipin IgA high postive, IgG low positive, IgM normal. What do you offer the patient next? A. discuss that she has antiphospholipid syndrome and devise a treatment plan based on this diagnosis B. repeat antiphospholipid screen in 6-8 weeks C. start baby aspirin and heparin immediately D. start baby aspirin with next pregnancy E. none of the above |
E. non of the above, the patient does not have antiphospholipid syndrome based on these lab results
anticardiolipin IgA being positive is not part of the diagnostic criteria and the low positive IgG is also not positive |
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A couple with recurrent pregnancy losses gets karyotype analysis and the male partner is found to have a robertsonian translocation involving chromosomes 14 and 21. The female is normal. The most appropriate next step is:
A. offer IVF B. discuss the role of donor gametes C. offer IVF wtih preimplantation genetic diagnosis D. close observation with the next pregnancy E. send the couple for a consult with a genetic counselor |
E. genetic consult
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Patient with a history of 3 miscarriages presents to your office. Labs are: lupus anticoagulant screen negative, anticardiolipin IgG high positive, IgM normal. What would you offer next?
A. discuss that she has antiphospholipid syndrome and devise a treatment plan B. repeat antiphospholipid screen in 6-8 weeks C. order a hysterosalpingogram D. B & C E. none of the above |
D. repeat antiphospholipid screen and order a hysterosalpingogram- to confirm antiphospholipid syndrome, either anticardiolipin antibodies or lupus anticoagulant screen must be positive twice, with at least 6-8 weeks in between
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15 yo female is brought to your office complaining of severe dysmenorrhea that has become progressivelyworse since the onset of menses. Menarche started at 13. Pain is on the right side and lasts for the duration of bleeding and is associated with nausea and vomiting. She sometimes has to miss school. She has tried NSAIDs, but that no longer helps. Next step:
A. take max dose of NSAIDs B. refer to psychiatry C. start oral contraceptive pills D. get a pelvic US E. perform a laparoscopy to evaluate for endometriosis |
D. pelvic US- the pain is getting worse over time, and it localizes to one area- secondary dysmenorrhea, possibly d/t mullerian anomaly
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8yo is brought to your office b/c of bloody vaginal discharge. Her mom suspects sexual abuse because she doesn't know any other reason why her daughter would be bleeding. No PMHx except for a throat infection a few months ago, which was treated with ABX. On exam, she has enlargement of both breasts and enlarged areolae. No axillary hair growth or pubic hair. Age appropriate clitoris and labia minora. No bruises, hematomas or lacerations. You take a culture of the vaginal discharge, which is pink to red and not foul smelling. Cause:
A. precocious puberty B. sexual abuse C. foreign body D. bacterial infection E. pinworm |
D. hemolytic streptococcal throat infection that has translated into vaginitis weeks later
precocious puberty is unlikely in an 8 year old with isolated breast development |
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6 yo has had a 4 UTI within the last 3 months. There is lack of pubic hair. Labia minora are in apposition but are easily separable. You note a 1cm sized clitoris. There is a 0.3cm cystic structure in the inferior aspect of the urethra, which is non tender, but has a reddish discharge. You order a urinalysis. The next step is:
A. estrogen cream B. sitz bath C. IV pyelography D. low potency steroid cream E. surgical repair |
B. sitz baths- dx prolapsed urethra, characterized by a small, hemorrhagic, friable, painless mass surrounding the urethra
the safest and least expensive initial therapy is sitz baths, estrogen cream would be the next step |
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24 yo G1P1 just delivered a female infant. the infant weighed 3990g and had APGARs of 8 and 9 at 1 and 5 minutes. On inspection, pediatricians are unable to assign a gender because there is clitoral hypertorphy and the labia are partially fused. There are no masses palpated in between. Next step:
A. 17 oh progesterone level B. dehydroepiandrosterone level C. serum sodium level D. tell the parents they have a baby girl E. karyotype |
C. serum sodium- because congenital adrenal hyperplasia, esp 21 OH deficiency, is the most common cause of distinct virilization of females, efforts should be made to get electrolytes immediately because the salt wasting type of CAH can be life threatening
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Data:
Karyotype --> XY Spermatogenesis --> absent Mullerian structures --> absent Wolffian structures --> present External genitalia --> male hypospadias Breast --> gynecomastia Diagnosis: A. true hermaphroditism B. mixed gonadal dysgenesis C. swyer syndrome D. complete androgen insensitivity E. reifenstein syndrome |
E. reifenstein syndrome-- look this up
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50 yo woman has menses every 2-3 months and hot flashes that wake her. She falls asleep in the afternoon at work because she doesn't sleep at night. She asks you if she is at risk for becoming pregnant with unprotected intercourse and wants your advice. You should:
A. check FSH levels B. advise her that she is too old to conceive C. advise her to use natural family planning D. discuss using combo hormonal contraceptive E. recommend she have a tubal ligation |
D. discuss using combo hormonal contraceptive- it will provide contraception and relief of her vasomotor symptoms
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35yo G2P2 presents with regular menses since 14, until last year. Her hCG is negative, serum estradiol less than 20, FSH and LH greater than 100, and prolactin less than 20. She has hot flashes and dyspareunia that disrupt her life. Which is NOT true?
A. patient is at increased risk of bone loss and fracture compared to menstruating women B. patient has premature ovarian failure and should be offered HT both for her sx and to protect her from bone loss C. typical menopause D. patient should receive progestogen in addition to estrogen if she chooses to take systemic hormones E. vaginal estrogens will relieve her genitourinary sx |
C. this is NOT a typical menopausal woman because she is so young. She has premature ovarian failure, defined as menopause prior to age 40
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current studies about the risks and benefits of HT/ET (hormone therapy/estrogen therapy) put perimenopausal and menopausal women in a treatment dilemma. Which is true?
A. woman using HT have twice the risk of developing breast cancer compared to healthy menopausal women B. HT prevents all cause dementia in women C. HT/ET should be given in the lowest doses for the shortest duration of time needed to achieve the desired effect D. if a woman with breast ca has sx duet to chemotherapy induced menopause, she has no available pharmacologic agents available to her E. HT/ET is indicated for prevention of skin changes d/t estrogen deficiency and for prevention of CV disease |
C. lowest dose for shortest time
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70yo woman with her final menstrual period (FMP) at 51 complains of back pain and a 4 inch loss in height. Spine films confirm the presence of multiple osteoporosis related vertebral compression fractures. Her DEXA T score is -2.7. Concerns for management include all but:
A. potential risk for future hip fracture B. assessment of risk of falling C. concern that the positive smoking hx will exclude her from therapy to prevent future fractures D. concern that a SERM may not be as effective as a bisphosphonate in treating this patient E. concern that the patient's immobility may limit her ability to perform weight bearing exercise or go outside for sun exposure to increase endogenous vit D |
C. smoking is a major risk factor for osteoporosis and fracture, current smoking is not exclusionary from any of the approved osteoporosis medications
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55 year old woman with her final menstrual period at age 50 presents with a history of 3 days of light vaginal bleeding. You should:
A. give her vaginal estrogen for atrophic vaginits and tell her to come back if the bleeding doesn't subside B. Perform a hysterectomy and bilateral salpingo-oopherectomy to rule out endometrial cancer C. take a hx, perform a physical, perform endometrial tissue sampling and order a pelvic US D. recommend she go on a diet E. start estrogen therapy, instead of hormone therapy, since adding a progesterone may make her bleed |
C. although post menopausal bleeding is common, it is not normal, this patient needs to be evaluated for endometrial neoplasia
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24 yo G3P3 who just delivered a healthy boy is breastfeeding him. She is a successful model and cannot tolerate excessive weight gain. She has never been able to remember to take a pill daily. What contraceptive method is best for her?
A. Depot shot B. Progestin only pill C. Combo birth control pill D. progesterone IUD E. vaginal contraceptive ring |
D. progesterone IUD- women how are breastfeeding should use progestin only contraceptive methods so as not to affect the quantity and quality of their milk; depo has a 5lb weight gain/year
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29 year old nulliparous woman who has factor V leiden deficiency and a bicournuate uterus. She is a librarian who exercises 6 days/week in order to maintain her physique. She has had multiple sexual relationships this year. She tries to use condoms in addition to this contraceptive method to prevent STDs. What contraceptive method is best for her?
A. Depot shot B. Progestin only pill C. Combo birth control pill D. progesterone IUD E. vaginal contraceptive ring |
B. progestin only pill- she should avoid estrogen because of her inherited thrombophilia, avoid depo because she is concerned about weight gain, she is not a candidate for IUD d/t abnormal uterine cavity
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28yo nulliparous physician with a hx of major depression. She is on call in the hospital every 4 days and sometimes forgets to take her antidepressants. She has been in a new relationship for the past 4 months. She always uses a condom in addition to her contraception. What contraceptive method is best for her?
A. Depot shot B. Progestin only pill C. Combo birth control pill D. progesterone IUD E. vaginal contraceptive ring |
E. vaginal contraceptive ring
she already has depression and the depo shot is associated with depression, the IUD is not contraindicated in nulliparous women, but insertion may be uncomfortable, so a contraceptive ring is the best option |
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26yo G4P4 female. She has regular periods that last 9-10 days, are very heavy and are associated with severe cramping. She is fairly sure she is done with childbearing. What contraceptive method is best for her?
A. Depot shot B. Progestin only pill C. Combo birth control pill D. progesterone IUD E. vaginal contraceptive ring |
D. progesterone IUD- dysmenorrhea and menorrhagia would improve
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24yo multiparous patient is interested in long term contraception, but is concerned that the copper IUD acts as an abortifacient. The best guidance you can give her is:
A. she should not use the copper IUD because its main mechanism of action is as an abortifacient B. the main way in which the copper IUD prevents pregnancy is by acting as a spermicide C. tubal ligation is more effective at long term contraception that an IUD D. IUD is associated with a high rate of PID |
B. the copper IUD is effective because of the copper's spermacidal action
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25yo G1P0 + 1 therapeutic abortion presents to the ER and is being evaluated for date rape that occured 12 hours ago. She says the rapist was able to ejaculate inside her. In addition to prophylactic treatment for STDs, complete rape eval, and counseling, the most effective and widely available management to prevent pregnancy is:
A. ethinyl estradiol and norgestrel- two tablets now and two in two hours B. ethinyl estradiol and norgestrel- two tablets now and two in two hours, and prochlorperazine C. Plan B 150mg now D. Levonorgestrel, 0.75mg now and another in 12 hours E. mifepristone |
C. Plan B- the progesin method is more effective in preventing pregnancy than the combination pill
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The following describes which agent?
Papular rash, arthritis, and perihepatic 'violin-string' adhesions. |
advanced disseminated gonococcal infection can give rise to septic arthritis, rash, and fitz hugh curtis syndrome
gonorrhea is a gram negative diplococci |
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The following describes which agent?
vulvar ulcer, marked inguinal lymphadenopathy, diagnosis by complement fixation |
Lymphogranuloma venereum caused by chlamydia thachomatis serotypes L1-L3- it consists of genital ulcers, tender inguinal lymphadenopathy and fistula formation in advanced cases
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The following describes which agent?
Congenital infection consisting of nonimmune hydrops, skin rash and hepatomegaly. |
Untreated congenital syphillis may cause stillbirth, nonimmune hydrops, jaundice, hepatosplenomegaly, and skin rash
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22 yo nulligravid woman presents because of a 5 day history of frequent urination and dysuria. She was seen by a doctor 2 days ago and prescribed ampicillin. She has no remarkable medical history. She is sexually active and recently began sleeping with her new boyfriend. She has no known drug allergies. Her urinalysis shows: 2+ squamous cells, 0 nitrites, 18 WBC/hpf, 0 bacteria and negative hCG. The next best step in management is:
A. ceftriaxone B. TMP-SMX C. spectinomycin D. azithromycin E. observation |
D. azithromycin-- symptoms of urethritis (frequency and dysuria) and pyuria (WBC in urine) with a negative urine culture in a sexually active woman suggests chlamydial infection.
DOC in a non pregnant patient is single dose azithromycin or doxycycline. |
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26 yo G1P0 at 14 weeks presents because of increased vaginal discharge. You perform a wet mount and test for gonorrhea and chlamydia. The results are positive for chlamydia. The next step in management is:
A. azithromycin + test of cure 5 weeks + rescreen 4 months B. doxycycline + test of cure 5 weeks + rescreen 5 months C. ofloxacin + test of cure 4 weeks + rescreen 4 months D. erythromycin + test of cure 3 weeks + rescreen 4 months E. erythromycin + test of cure 2 weeks + rescreen 3 months |
A. Azithromycin + test of cure 5 weeks + rescreen 4 months
although the best studies of management of chlamydia during pregnancy involve an erythromycin base, azithromycin may also be used and it no contraindicated. doxy and ofloxacin are contraindicated during pregnancy because they damage teeth and cartilage, respectively The test of cure must be performed in more than 4 weeks |
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20 yo presents with deep, excavating, painless lesion above the clitoris, overlying the pubic bone. Her serum VDRL is positive. A lumbar puncture and analysis of her CSF also yields a positive VDRL. The best term to describe her lesion is:
A. condyloma acuminatum B. condyloma latum C. chancre D. gumma E. bubo |
D. gumma- tertiary syphilis (neurosyphilis) is diagnosed with ophthalmic signs in someone whose serum is VDRL positive, or in someone with gummas whose CSF tests positive for VDRL.
condyloma latum is indicative of secondary syphilis |
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17 year old presents with intense itching in her pubic region. You perform a wet prep and KOH but are unable to find anything. Exam of her pubic hair in the area of the mods with a hand lens reveals several linear lesions and adjacent erythema from self scratching. Her pregnancy test is negative. The next best step in management is neck down treatment with:
A. permethrin 1% for 10 hours + clean toilet seats B. permethrin 5% for 10 hours + wash bed sheets C. permethrin %5 for 10 minutes + clean toilet seats D. lindane 1% for 4 minutes + washing clothing E. lindane 1% for 8 hours + wash bed sheets |
B. permethrin 5% for 10 hours + wash bed sheets- treatment of scabies usually consists of more potent agents, longer duration of treatment and neck down treatment in contrast to treatment of lice
all bedding and clothing needs to be washed, flat smooth surfaces such as toilet seats are not risk factors for acquisition of scabies of lice permethrin 1% is not powerful enough, lindane 1% for 4 minutes is not long enough, and lindane is contraindicated in pregnancy d/t toxicity |
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19 yo whose LMP was 32 days ago and who is sexually active, presents to the ER with a 5 day history of lower abdominal pain. Her vitals are: T=101, BP= 110/75, P= 80, R= 16. Speculum exam reveals purulent exudate at the cervical os, and there is cervical motion tenderness. Bimanual exam is unremarkable for masses, but produces severe discomfort. Her hCG= 150mIU/mL. Urinalysis is normal. WBC count is 14,000. An office US shows a normal sized, normal striped uterus and no adnexal masses. The next best step in management is:
A. repeat serum hCG in 48 hours B. Penicillin G IV C. ampicillin and gentamicin IV D. clindamycin and gentamicin IV E. cefazolin and doxycycline IV |
D. clindamycin and gentamicin
Patient has acute PID and happens to be pregnant also-- regimen of clindamycin and gentamicin is appropriate because the patient is pregnant-- provides coverage for anaerobic, aerobic, N. gonorrheae and C. trachomatis |
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The most important reason that PID must be recognized and treated promptly is the prevention of:
A. pelvic pain syndrome B. infertility C. ectopic pregnancy D. tubo ovarian abscess E. pelvic adhesive disease |
D. tubo ovarian abscess-- mortality does occur, particularly in neglected cases in which a rupture tubo ovarian abscess can lead to septic shock and death
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17 yo woman has sx suggestive of PID. However, the patient is adamant that she is a virgin. If the signs of PID are present because of inflammation involving the uterus, tubes, and ovaries, the most likely diagnosis is:
A. tuberculosis B. endomyometritis C. schistosomiasis D. appendicitis E. ectopic pregnancy |
B. endymyometritis- inflammation of the tubes and ovaries can be seen in conjunction with any of the conditions listed --> bacterial infection involved in appendicitis can cause secondary tubal infection and is the most likely diagnosis
patient with a false positive diagnosis of PID were found at laparoscopy to have appendicitis (#1), endometriosis (#2) |
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22 yo G1P0, 1 total abortion, presents to ED with a 6 day history of lower abdominal pain and purulent vaginal discharge. She denies past medical history or surgery. Her vitals are: T=102, BP= 118/78, P=96, R=14. Bowel sounds are present, and there is tenderness in the lower pelvic region of the abdomen. There is no rebound tenderness of guarding. Her speculum exam reveals white exudate at the external os of the cervix. Bimanual exam reveals severe cervical motion tenderness and uterine tenderness. There is also a fullness in the left adnexa. Her urine hCG is negative and WBC count= 15,000. The next best step in management is:
A. pelvic US B. CT C. quantitative hCG D. immediate hospitalization E. ceftriaxone IM plus doxycycline orally |
A. US-- because this patient has sx and signs of PID along with an adnexal mass, you must evaluate for a tubo ovarian abscess before diagnosing the patient with uncomplicated PID and sending her home on oral treatment
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22 yo G1P0, 1 total abortion, presents to ED with a 6 day history of lower abdominal pain and purulent vaginal discharge. She denies past medical history or surgery. Her vitals are: T=102, BP= 118/78, P=96, R=14. Bowel sounds are present, and there is tenderness in the lower pelvic region of the abdomen. There is no rebound tenderness of guarding. Her speculum exam reveals white exudate at the external os of the cervix. Bimanual exam reveals severe cervical motion tenderness and uterine tenderness. There is also a fullness in the left adnexa. Her urine hCG is negative and WBC count= 15,000. The most important reason to admit this patient to the hospital is:
A. WBC count B. temperature C. pelvic exam D. age E. patient is unreliable |
C. pelvic exam-- a tubo ovarian abscess or pelvic abscess may first be appreciated on pelvic exam and can be further evaluated with an US
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Married, 26 yo G4P3 presents for prenatal care. Upon measuring her fundus, you notice several bruises in the shape of long cylindric objects on her shins and thighs. How do you address this?
A. 'When did your husband beat you?' B. 'Did your husband use a broomstick to beat you?' C. ' Are you afraid of your husband?' D. ' If your husband physically abusing you with objects around the house?' E. ' Is your relationship with your husband one that makes you want to hide from him?' |
C. 'Are you afraid of your husband?'
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27 yo G3P2, spontaneous abortion 1, has been beaten many times by her husband. She wants help, but has not told anyone, probably because...
A. she does not want to talk about the issue B. she is afraid of breaking up her family C. it is not a medical issue D. she is afraid of retaliation by the partner E. she has deep rooted masochistic tendencies |
D. she is afraid of retaliation by her partner
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A woman discloses to her physician that her husband beats her when he is drunk. The physician's main role is to:
A. help the patient understand why she must leave the relationship immediately B. accept that this is a personal issue and not interfere C. report the abuse to the national center for injury prevention and control D. involve a social worker E. focus on patient safety issues, such as exit plans and copies of important documents |
E. focus on patient safety issues
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Intimate partner violence significantly increases in incidence:
A. after the first year of marriage B. shortly after the birth of an infant C. after one partner retires D. after a couple's children have left the home E. in a household where one partner is a homemaker and the other a provider |
B. after the birth of an infant
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36 yo G4P4 presents to the clinic because she has had bilateral white colored nipple discharge for the last three months. She has no medical history other than depression, for which she takes a tricyclic antidepressant. She is married and uses birth controls pills. Exam of the breasts reveals no masses. When the nipple discharge is placed on a slide, fat globules are seen that are reminiscent of milk. What is the next best step?
A. obtain a prolactin level B. schedule a follow up in 6 weeks C. collect discharge for cytopathology D. discontinue antidepressant E. substitute nonhormonal method of contraception |
A. obtain a prolactin level-- although the most likely cause of the galactorrhea is medication related, you must rule out a pituitary adenoma first
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30 yo G2P2 woman presents to your office reporting a mass in her right breast that she just noticed on a self breast exam. She has no medical problems. There is no history of breast or ovarian cancer in her family. Her exam is notable for a 2 cm mass in her right breast that is smooth, mobile, and nontender. Your next step is:
A. reassure her that the mass is benign B. recommend vit E C. obtain an US of the mass D. refer her to a breast surgeon for excision of the mass E. recommend a mammogram |
C. obtain a US of the mass-- if the lesion is cystic, then aspiration would be indicated; if it is solid, mammogram should be considered
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60 yo G3P2, spontaneous abortion 1, presents to your clinic reporting brownish red colored discharge from her left nipple. Her past medical history and meds are as follows: diabetes, oral hypoglycemic; hypertension, ACEi; major depression, fluoxetine. She is also taking conjugated estrogen with medroxyprogesterone acetate daily. She is allergic to PCN. She says her mother was diagnosed with ovarian cancer at age 71. What is the next best step in management?
A. mammogram B. fine needle aspiration C. referral to breast surgeon D. cessation of hormone replacement therapy E. ultrasound |
E. ultrasound
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28 yo G2P2 who delivered a healthy female 10 days ago, comes in to labor and delivery because of a tender breast mass on the right. She is breast feeding exclusively. On exam, you note bilateral mild engorgement of the breasts and a tender, firm, linear, and slightly erythematous cord in the lateral aspect of her right breast. What is the next best step in management?
A. observation B. heat compresses C. mammogram D. biopsy E. dicloxacillin |
B. heat compresses- most likely diagnosis is Mondor disease (superficial thrombophlebitis of the right thoracoepigastric vein)
the condition is self limited |
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The embryologic homolog in the male is the cowper glands.
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Bartholin gland
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This is the source of vaginal lubrication during intercourse.
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cervical secretions
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23 yo G2P1 at 10 weeks presents to your office and reports increasing yellow vaginal discharge that has an odor. A vaginal smear reveals clue cells. She denies pruritis. She has no allergies. The next step in management is:
A. oral metronidazole B. vaginal metronidazole C. oral clindamycin D. vaginal clindamycin E. oral fluconazole |
B. vaginal metronidazole-- oral metronidazole is contraindicated in the first trimester
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25 yo G1P1 presents to your office reporting four recurrent yeast infections within the last 2 months. You perform a wet mount and a 10% KOH prep and confirm presence of many pseudohyphae and absence of clue cells or leukocytes. She is not pregnant, is not on birth control, and has not been sexually active for 7 months. What is the next step in management?
A. screen for STDs B. long term oral ketoconazole C. boric acid capsules intravaginally D. screen for HIV E. random glucose level |
D. screen for HIV-- patients with recurrent or recalcitrant fungal infection may be immunocompromised, therefore HIV testing is indicated
screening for diabetes is also indicated, but that is done with a fasting glucose level, not a random long term treatment may be indicated, but evaluation her for an immunocompromised state is first |
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19 yo woman complains of increasing discharge and odor. Her pH is 5.5, and wet mount reveals lack of leukocytes and protozoa.
A. bacterial vaginosis B. moniliasis C. trichomoniasis D. herpes simplex E. atrophic vaginitis F. lichen sclerosus G. hyperplastic dystrophy H. traumatic vaginitis |
A. bacterial vaginosis
the only discharges that have a pH higher than 4.2 are bacterial vaginosis, trichomoniasis, and atrophic vaginitis |
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24 yo woman who is 2 months post partum and is breastfeeding reports itching and dyspareunia. Speculum exam reveals pale, dry vaginal walls.
A. bacterial vaginosis B. moniliasis C. trichomoniasis D. herpes simplex E. atrophic vaginitis F. lichen sclerosus G. hyperplastic dystrophy H. traumatic vaginitis |
E. atrophic vaginitis- typical d/t estrogen deficiency
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A wet mount shows a predominance of cells with large nuclei (parabasal cells).
A. bacterial vaginosis B. moniliasis C. trichomoniasis D. herpes simplex E. atrophic vaginitis F. lichen sclerosus G. hyperplastic dystrophy H. traumatic vaginitis |
E. atrophic vaginitis- typical d/t estrogen deficiency
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60 yo G5P4, spontaneous abortion 1, has been treated with vaginal estrogen therapy, various pelvic muscle rehab therapies, and pessaries for symptoms of pelvic prolapse without incontinence for the past 2 years. She desires definitive therapy. He has no medical history other than HTN, for which she takes HCTZ. All of her children were delivered vaginally. On exam, the vaginal mucosa is pink and moist. The anterior vaginal wall prolapses up to the hymenal ring on valsalva. When the anterior vagina is supported with half of the speculum, the uterus and cervix prolapse past the hymenal ring as well. there is no stree incontinence when the urethrovesical junction is supported and the cystocele reduced. The uterus is normal in size, contour, and consistency. The sacral neurologic exam is unremarkable. A urine culture is sent. The next step is:
A. electrical stimulation of the pelvic musculature B. abdominal hysterectomy and anterior repair C. vaginal hysterectomy and anterior repair D. vaginal hysterectomy, anterior repair, and suburethral sling E. burch retropubic urethropexy and anterior repair |
C. vaginal hysterectomy and anterior repair-
the patient has uterine prolapse and cystocele, and conservative treatment has failed, therefore the next best treatment is surgical. Cystocele can be cured with anterior repair uterine prolapse can be cured with a hysterectomy |
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32 yo G3P3 just delivererd a viable female weighting 4000g via c section for a nonreassuring fetal heart rate pattern. She received intrathecal anesthetic and narcotic for pain relief during the procedure. Her Foley catheter is left in place for several hours after the procedure. This will prevent:
A. stress incontinence B. urge incontinence C. overflow incontinence D. bypass incontinence E. postop UTI |
C. overflow incontinence
anesthetics and narcotics block nerve impulses to and from the bladder --> when the bladder becomes distended with urine, the afferent impulses cannot be transmitted, and therefore the bladder detrusor muscle is underactive --> overdistention and incontinence |
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56 yo G2P2 reports leaking urine when she coughs and exercises. She is diagnosed with genuine stress urinary incontinence. Kegel exercises do not improve her symptoms, and she desires more definitive treatment. Her doctor recommends laparoscopic retropubic urethropexy. When discussing the risks and benefits of the laparoscopic Burch procedure, the doctor should mention:
A. low short term cure rates B. 60% long term cure rates C. risk of urinary retention D. alternative of drug therapy E. risk of graft infection and ulceration |
C. risk of urinary retention
the long and short term cure rates are very high (90%) the main complication is the small risk of urinary retention |
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67 yo G3P3 presents reporting incontinence. She tell you she voids almost 40 times/day and has several episodes of nocturia. When she makes it to the bathroom, only small amounts of urine are voided. Her past medical hx is remarkable for mild asthma, for which she takes albuterol. Her previous gynecologist put her on an estrogen patch, estrogen vaginal cream and intravaginal progesterone tablets. Her BP= 130/80, P=80, height= 5'4'', weight= 230#. ON physical exam you notice pink, moist vaginal epithelium with mild cystocele and well supported proximal urethra. The next best management is:
A. urinalysis B. tolterodine C. pseudoephedrine D. pessary E. suburethral sling |
A. urinalysis
although the scenario is almost definitely urge incontinenct, you must rule out UTI because it may mimic symptoms of urgency once UTI is ruled out, you can start therapy with tolterodine or oxybutynin |
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55 yo G3P3 who delivered all of her children via c section has mild pelvic organ prolapse. She had her last period 3 years ago and since that time has been on estrogen patches and progesterone vaginal tablets for treatment of hot flushes and vaginal dryness. She is currently on antibiotics for acute bronchitis. Her family history is significant for osteoporosis diagnosed at an earlier age than average in her mother, two sisters and grandmother. The strongest risk factor for pelvic relaxation in this patient is:
A. parity B. age C. hormone status D. genetic E. cough |
D. genetic- the cause of pelvic organ prolapse is multifactorial- genetics determine the subtype and density of collagen and CT that a person inherits
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Advanced cervical cancer can affect this structure by extension and pressure effects.
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ureter --> hydronephrosis
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Advanced ovarian cancer often affects this structure by spread and encroachment.
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intestines --> bowel obstruction
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HPV is associated with the development of cervical, vaginal, vulvar, and anal cancers. Which statement is true?
A. HPV types 16 and 18 are detected in 95% of cervical cancers B. the vaccine that is currently approved for prevention of HPV is over 95% effective in preventing HPV 16 and 18 C. by age 50, 46% of women in the US will have acquired a genital HPV infection D. HPV types 6 and 11 are oncogenic and therefore are most often associated with genital warts E. 95% of HPV infections are transient and will be cleared in 1-2 years |
B. the approved quadrivalent vaccine appears to be over 95% effective in preventing HPV 16 and 18
HPV 16 and 18 accounts for 70% of all cervical cancers by age 50, 80% of women in the US will have HPV |
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What is the most common histology for cervical cancer?
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Squamous
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What is the most common malignant germ cell tumor?
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Dysgerminoma
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Read chapter 40.
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DO IT. It's just ethics.
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