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26 Cards in this Set
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A 36-year-old G2P2 woman presents with irregular vaginal bleeding. Six weeks ago, she had her first Depo-Provera injection and now she has unpredictable bleeding. She is concerned by these symptoms. She has a history of hypertension but is currently on no medications. Vital signs reveal: blood pressure 130/90; weight 188 pounds; height 5 feet 5 inches; BMI 31.4kg/m2. Which of the following is the most appropriate next step in the management of this patient?
A. Reassurance B. Begin oral contraceptives C. Begin estrogen D. Insert etonogestrel implant (Implanon) E. Perform an endometrial biopsy |
Reassurance. Depo-Provera injection there may be unpredictable bleeding. This usually resolves in 2-3 months.
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A 23-year-old G0 woman with last menstrual period 14 days ago presents to the office because she had unprotected intercourse the night before. She does not desire pregnancy at this time and is requesting contraception. She has no medical problems and is not taking any medications. In addition to offering her counseling and testing for sexually transmitted infections, which of the following is the most appropriate next step in the management of this patient?
-Provide emergency contraception, and return after next menstrual period - Provide emergency contraception, then begin oral contraceptives immediately |
Provide emergency contraception, then begin oral contraceptives immediately.
Emergency contraceptive pills are not an abortifacient, and they have not been shown to cause any teratogenic effect if inadvertently administered during pregnancy. They are more effective the sooner they are taken after unprotected intercourse, and it is recommended that they be started within 72 hours, and no later than 120 hours. Plan B, the levonorgestrel pills, can be taken in one or two doses and cause few side effects. Emergency contraceptive pills may be used anytime during a woman’s cycle, but may impact the next cycle, which can be earlier or later with bleeding ranging from light, to normal, to heavy. |
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Ideal candidates for progestin-only pills include
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history of thromboembolic disease, women who are lactating, women over age 35 who smoke or women who develop severe nausea with combined oral contraceptive pills. Progestins should be used with caution in women with a history of depression.
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A 24-year-old G1P1 woman comes to the office requesting contraception. Her past medical history is unremarkable, except for a family history of ovarian cancer. She denies alcohol, smoking and recreational drug use. She is in a monogamous relationship. She wants to decrease her risk of gynecological cancer. Of the following, what is the best method of contraception for this patient?
A. Female condoms B. Male condoms C. Copper containing intrauterine device D. Progesterone containing intrauterine device E. Combined oral contraceptives |
Combined oral contraceptives. Oral contraceptives will decrease a woman’s risk of developing ovarian and endometrial cancer.
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A 35-year-old G3P3 woman comes to the office to discuss tubal ligation as she desires permanent sterilization. The non-contraceptive health benefits of female sterilization reduce the risk of which of the following?
A. Breast cancer B. Ovarian cancer C. Endometrial cancer D. Cervical cancer E. Menorrhagia |
Ovarian cancer. Tubal ligation has not been shown to reduce the risk of breast, cervical, or endometrial cancers, nor is there a decrease in menstrual blood flow in women who have undergone a tubal ligation. There is a slight reduction in the risk of ovarian cancer, but the mechanism is not yet fully understood.
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A 32-year-old G3P3 woman comes to the office to discuss permanent sterilization. She has a history of hypertension and asthma (on corticosteroids). She has been married for 10 years. Vital signs show: blood pressure 140/90; weight 280 pounds; height 5 feet 9 inches; and BMI 41.4kg/m2. You discuss with her risks and benefits of contraception. Which of the following would be the best form of permanent sterilization to recommend for this patient?
A. Laparoscopic bilateral tubal ligation B. Mini laparotomy tubal ligation C. Exploratory laparotomy with bilateral salpingectomy D. Total abdominal hysterectomy E. Vasectomy for her husband |
Vasectomy for her husband. Vasectomies are performed as an outpatient procedure under local anesthesia, while tubal ligations are typically performed in the operating room under regional or general anesthesia; therefore carrying slightly more risk to the woman, assuming both are healthy. She is morbidly obese, so the risk of anesthesia and surgery are increased. In addition, she has chronic medical problems that put her at increased risk of having complications from surgery.
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A 35-year-old G3P3 woman comes to the office because she desires contraception. Her past medical history is significant for Wilson’s disease, chronic hypertension and anemia secondary to menorrhagia. She is currently on no medications. Her vital signs reveal a blood pressure of 144/96. Which of the following contraceptives is the best option for this patient?
A. Progestin-only pill B. Low dose combination contraceptive C. Continuous oral contraceptive D. Copper containing intrauterine device E. Levonorgestrel intrauterine device |
Levonorgestrel intrauterine device. The levonorgestrel intrauterine device is protective against endometrial cancer due to release of progestin in the endometrial cavity. She is not a candidate for oral contraceptive pills because of her poorly controlled chronic hypertension. The progestin only pills have a much higher failure rate than the progesterone intrauterine device. She is not a candidate for the copper-containing intrauterine device because of her history of Wilson’s
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A 23-year-old G0 woman comes to the office to discuss contraception. Her past medical history is remarkable for hypothyroidism and mild hypertension. She has a history of slightly irregular menses. Her best friend recently got a “patch,” so she is interested in using a transdermal system (patch). Her vital signs are: blood pressure 130/84; weight 210 pounds; height 5 feet 4 inches. What is the most compelling reason for her to use a different method of contraception?
A. Age B. Hypothyroidism C. Weight D. Unpredictable periods E. Hypertension |
Weight. The patch has comparable efficiency to the pill in comparative clinical trials, although it has more consistent use. It has a significantly higher failure rate when used in women who weigh more than 198 pounds. The patch is a transdermal system that is placed on a woman’s upper arm or torso (except breasts). The patch (Ortho Evra) slowly releases ethinyl estradiol and norelgestromin, which establishes steady serum levels for seven days. A woman should apply one patch in a different area each week for three weeks, then have a patch-free week, during which time she will have a withdrawal bleed.
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A 20-year-old G2P2 healthy woman presents for her post-partum check six weeks after a full term normal spontaneous delivery. She has a 13 month old in addition to the six-week newborn, and is already feeling overwhelmed. She desires a reliable form of contraception. On exam, her vital signs are normal. BMI is 27. The remainder of the exam is unremarkable. Of the following, what is the most effective form of contraception for this patient?
A. Intrauterine device B. Tubal ligation C. Depo-Provera D. Oral contraceptive pills E. Essure |
Intrauterine device. While Depo-Provera is an effective form of contraception, it may not be the best choice in this woman with a high BMI. For this young mother who desires a reversible, but reliable form of contraception, the high effectiveness, continuation rate and user satisfaction of LARC methods would be of most benefit. Emerging evidence indicates that increasing the use of LARC methods also could reduce repeat pregnancy among adolescent mothers and repeat abortions among women seeking induced abortion. (“Increasing Use of Contraceptive Implants and Intrauterine Devices To Reduce Unintended Pregnancy,” ACOG Committee Opinion, No. 450, 2009). Tubal ligation and Essure are permanent and are not appropriate for this patient.
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A 23-year-old G2P1 woman with six weeks amenorrhea presents with lower abdominal pain and vaginal bleeding. Her temperature is 102.0°F (38.9°C) and the cervix is 1 cm dilated. Uterus is eight-week size and tender. There are no adnexal masses. Urine pregnancy test is positive. What is the most likely diagnosis?
A. Threatened abortion B. Missed abortion C. Normal pregnancy D. Septic abortion E. Ectopic Pregnancy |
Septic abortion. Treatment is Uterine evacuation plus antibiotics
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A 29-year-old G3P0 woman presents for evaluation and treatment of pregnancy loss. Her past medical history is remarkable for three early (<14 weeks gestation) pregnancy losses. Parental karyotype was normal. Which of the following is the most appropriate next step in the management of this patient?
A. Place a prophylactic cerclage with her next pregnancy B. Obtain serial cervical length with her next pregnancy C. Recommend 17-hydroxyprogesterone with her next pregnancy D. Check for Factor V Leiden mutation E. Check antiphospholipid antibodies |
Check antiphospholipid antibodies. Treatment with 17-hydroxyprogesterone is indicated in patients with a history of prior preterm birth. Factor V Leiden mutation has not been associated with recurrent pregnancy loss. It can be associated with thrombotic events.
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A 29-year-old G3P0 woman presents for evaluation and treatment of pregnancy loss. Her past medical history is remarkable for three early (<16 weeks gestation) pregnancy losses and a deep vein thrombosis two years ago. Her work up includes: prolonged dilute Russell viper venom test; elevated anticardiolipin antibodies; normal thyroid function; normal prolactin; and normal MRI of the pelvis. She wishes to get pregnant soon. In addition to aspirin, which of the following treatments is appropriate for this patient?
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The prolonged dilute Russell viper venom time leads one to suspect that the etiology of recurrent pregnancy loss is due to antiphospholipid antibody syndrome. The treatment is aspirin plus heparin.
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A 25-year-old G1 woman at six weeks gestation comes to the office because of undesired pregnancy. You discuss with her the risks and benefits of surgical versus medical abortion using misoprostol and mifepristone. Compared to surgical abortion, which of the following is increased in a woman undergoing a medical abortion?
A. Post abortion pain B. Lower failure rate C. Long-term psychological sequelae D. Blood loss E. Future infertility |
Blood loss. Medical abortion is associated with higher blood loss than surgical abortion
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A 36-year-old G2P0 woman at 11 weeks gestational age requests a surgical termination of pregnancy. She had a manual vacuum aspiration last year and would like to undergo the same procedure again. She has chronic hypertension and diabetes well controlled on medications. Vital signs reveal a blood pressure of 120/80 and fasting blood glucose of 100. Which of the following is a contraindication for manual vacuum aspiration of this patient?
A. Age B. Parity C. Gestational age D. Chronic hypertension E. Diabetes |
Gestational age. Manual vacuum aspiration is more than 99% effective in early pregnancy (less than eight weeks)
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A 25-year-old G1 woman at 20 weeks gestation desires termination of the pregnancy. Her prenatal course has been unremarkable except for a chromosomal analysis positive for Trisomy 18. She desires an autopsy of the fetus. Which of the following is the most appropriate next step in the management of this patient?
A. Perform a dilation and curettage B. Perform a dilation and evacuation C. Await fetal demise then start induction of labor D. Perform an induction with oxytocin E. Perform an induction with intravaginal prostaglandins |
Perform an induction with intravaginal prostaglandins. Both medical and surgical abortions are options for this patient, depending on her personal preferences. However, if she desires an autopsy, she must undergo a medical abortion in order to have an intact fetus. Abortion is legal until viability is achieved (24 weeks gestation) unless a fetal anomaly inconsistent with extrauterine life is identified. A dilation and curettage is performed if the fetus is less than 16 weeks, while dilation and evacuation can be performed after 16 weeks by those trained in the procedure. Induction with oxytocin at this early gestational age has a high failure rate.
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A 23-year-old G1 woman at six weeks gestation undergoes a medical termination of pregnancy. One day later, she presents to the emergency room with bleeding and soaking more than a pad per hour for the last five hours. Her blood pressure on arrival is 110/60; heart rate 86. On exam, her cervix is 1 cm dilated with active bleeding. Hematocrit on arrival is 29%. Which of the following is the most appropriate next step in the management of this patient?
A. Admit for observation B. Repeat hematocrit in six hours C. Begin transfusion with O-negative blood D. Give an additional dose of prostaglandins E. Perform a dilation and curettage |
Perform a dilation and curettage. This patient is having heavy bleeding as a complication of medical termination of pregnancy. This is managed best by performing a dilation and curettage. It is not appropriate to wait six hours before making a decision regarding next step in management, or to just admit her for observation. Since the patient is not symptomatic from her anemia, it is not necessary to transfuse her at this time.
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A 22-year-old G1 woman with LMP six weeks ago presents for elective termination of pregnancy. She is healthy with no medical problems. An ultrasound performed in the office shows an 8 mm endometrial stripe with no intrauterine gestational sac and no adnexal masses. Which of the following is the most appropriate next step in the management of this patient?
A. Obtain a Beta-hCG level B. Perform dilation and curettage C. Give patient methotrexate D. Perform a diagnostic laparoscopy E. Prescribe mifepristone and misoprosto |
Obtain a Beta-hCG level. Even though the patient reports being pregnant, she is asymptomatic with no gestational sac in the uterus. First step in her management is to establish pregnancy by obtaining a Beta-hCG level. One should not assume she has an intrauterine pregnancy and perform a dilation and curettage or assume that she has an ectopic pregnancy and treat her with methotrexate or surgery until the pregnancy is confirmed.
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A 24-year-old G2P1 woman who underwent an elective termination two days ago presents to the emergency room with abdominal and pelvic pain. She has been feeling nauseated and reports a fever at home. On presentation, her blood pressure is 100/60; pulse 100; respiration 16; temperature 102°F (38.9°C). Physical examination reveals diffuse abdominal tenderness and, on pelvic examination, she has marked cervical motion tenderness. In addition to sending a CBC and cultures, which of the following is the most appropriate next step in the management of this patient?
A. Obtain a Beta-hCG level B. Order a hysterosonogram C. Begin IV antibiotics D. Proceed with a dilation and curettage E. Proceed with a laparoscopy |
Begin IV antibiotics. This patient has postoperative endometritis that could be due to introduction of bacteria into the uterine cavity at the time of dilation and curettage. It is important to begin antibiotics immediately. After starting antibiotics, an ultrasound should be obtained to look for products of conception. If found, the patient would then require a repeat dilation and curettage. A Beta-hCG level would not be helpful 2 days after the termination. Hysterosonogram is contraindicated when infection is present. There are no indications for laparoscopy in this patient.
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A 32-year-old nulliparous woman with a last menstrual period three weeks ago, presents with a three-month history of a malodorous vaginal discharge. She reports no pruritus or irritation. She has been sexually active with a new partner for the last four months. Her past medical history is unremarkable. Pelvic examination reveals normal external genitalia without rash, ulcerations or lesions. Some discharge is noted on the perineum. The vagina reveals only a thin, gray homogeneous discharge. The vaginal pH is 5.0. A wet prep is shown in the image below. Which of the following is the most appropriate treatment for this patient?
A. Ceftriaxone B. Doxycycline C. Metronidazole D. Azithromycin E. Penicillin |
Metronidazole. Bacterial vaginosis is the most common cause of vaginitis. The infection arises from a shift in the vaginal flora from hydrogen peroxide-producing lactobacilli to non-hydrogen peroxide-producing lactobacilli, which allows proliferation of anaerobic bacteria. The majority of women are asymptomatic; however, patients may experience a thin, gray discharge with a characteristic fishy odor that is often worse following menses and intercourse
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A 64-year-old G2P2 woman presents with a 12-month history of severe vulvar pruritus. She has applied multiple over-the-counter topical therapies without improvement. She has no significant vaginal discharge. She has severe introital dyspareunia and has stopped having intercourse because of the pain. Her past medical history is significant for allergic rhinitis and hypertension. On pelvic examination the external genitalia show loss of the labia minora with resorption of the clitoris (phimosis). The vulvar skin appears thin and pale and involves the perianal area as in the picture below. No ulcerations are present. The vagina is mildly atrophic, but appears uninvolved. Which of the following is the most likely diagnosis in this patient?
Squamous cell hyperplasia B. Lichen sclerosus C. Lichen planus D. Candidiasis E. Vulvar cancer |
Lichen sclerosus. Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects Caucasian premenarchal girls and postmenopausal women. The exact etiology is unknown, but is most likely multifactorial. Patients typically present with extreme vulvar pruritus and may also present with vulvar burning, pain and introital dyspareunia. Early skin changes include polygonal ivory papules involving the vulva and perianal areas, waxy sheen on the labia minora and clitoris, and hypopigmentation. The vagina is not involved. More advanced skin changes may include fissures and erosions due to a chronic itch-scratch-itch cycle, mucosal edema and surface vascular changes, and, ultimately, scarring with loss of normal architecture, such as introital stenosis, and resorption of the clitoris (phimosis) and labia minora. Treatment involves use of high-potency topical steroids. There is less than a 5% risk of developing squamous cell cancer within a field of lichen sclerosus.
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A 32-year-old G0 woman presents with a one-month history of profuse vaginal discharge with mild odor. She has a new sexual partner with whom she has had unprotected intercourse. She reports mild to moderate irritation, pruritus and pain. She thought she had a yeast infection, but had no improvement after using an over-the-counter antifungal cream. She is concerned about sexually transmitted infections. Her medical history is significant for lupus and chronic steroid use. Pelvic examination shows normal external genitalia, an erythematous vagina with a copious, frothy yellow discharge and multiple petechiae on the cervix. Vaginal pH is 7. Which of the following findings on a wet prep explains the etiology of this condition?
A. Hyphae B. Clue cells C. Trichimonads D. Lactobacilli E. Normal epithelial cells |
Trichimonads. Diagnosis of vaginal trichomoniasis is performed by saline microscopy of vaginal secretions, but this method has a sensitivity of only 60% to 70%. The CDC recommended treatment is metronidazole 2 grams orally in a single dose. An alternate regimen is metronidazole 500mg orally twice daily for seven days. The patient’s sexual partner also should undergo treatment prior to resuming sexual relations.
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A 42-year-old G2P2 woman presents with a two-week history of a thick, curdish white vaginal discharge and pruritus. She has not tried any over-the-counter medications. She is currently single and not sexually active. Her medical history is remarkable for recent antibiotic use for bronchitis. On pelvic examination, the external genitalia show marked erythema with satellite lesions. The vagina appears erythematous and edematous with a thick white discharge. The cervix appears normal and the remainder of the exam is unremarkable except for mild vaginal wall tenderness. Vaginal pH is 4.0. Saline wet prep reveals multiple white blood cells, but no clue cells or trichomonads. Potassium hydroxide prep shows the organisms. Which of the following is the most appropriate treatment for this patient?
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Azole cream. Vulvovaginal candidiasis (VVC) usually is caused by C. albicans, but is occasionally caused by other Candida species or yeasts.
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A 52-year-old nulliparous woman presents with long-standing vulvar and vaginal pain and burning. She has been unable to tolerate intercourse with her husband because of introital pain. She had difficulty sitting for prolonged periods of time or wearing restrictive clothing because of worsening vulvar pain. She recently noticed that her gums bleed more frequently. She avoids any topical over-the-counter therapies because they intensify her pain. Her physical examination is remarkable for inflamed gingiva and a whitish reticular skin change on her buccal mucosa. A fine papular rash is present around her wrists bilaterally. Pelvic examination reveals white plaques with intervening red erosions on the labia minora as shown in picture below. A speculum cannot be inserted into her vagina because of extensive adhesions. The cervix cannot be visualized. Which of the following is the most likely diagnosis in this patient?
A. Squamous cell hyperplasia B. Lichen sclerosus C. Lichen planus |
Lichen planus. Lichen planus is a chronic dermatologic disorder involving the hair-bearing skin and scalp, nails, oral mucous membranes and vulva. This disease manifests as inflammatory mucocutaneous eruptions characterized by remissions and flares. Vulvar symptoms include irritation, burning, pruritus, contact bleeding, pain and dyspareunia. Clinical findings vary with a lacy, reticulated pattern of the labia and perineum, with or without scarring and erosions as well. With progressive adhesion formation and loss of normal architecture, the vagina can become obliterated. Patients may also experience oral lesions, alopecia and extragenital rashes
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A 30-year-old G1P1 woman presents with a history of chronic vulvar pruritus. The itching is so severe that she scratches constantly and is unable to sleep at night. She reports no significant vaginal discharge or dyspareunia. She does not take antibiotics. Her medical history is unremarkable. Pelvic examination reveals normal external genitalia with marked lichenification (increased skin markings) and diffuse vulvar edema and erythema as shown in picture below. Saline microscopy is negative. Potassium hydroxide testing is negative. Vaginal pH is 4.0. The vaginal mucosa is normal. Which of the following is the most likely diagnosis in this patient?
. ALichen simplex chronicus B. Lichen sclerosus C. Lichen planus D. Candidiasis E. Vulvar cancer |
Lichen simplex chronicus. Lichen simplex chronicus, a common vulvar non-neoplastic disorder, results from chronic scratching and rubbing, which damages the skin and leads to loss of its protective barrier. Over time, a perpetual itch-scratch-itch cycle develops, and the result is susceptibility to infection, ease of irritation and more itching. Symptoms consist of severe vulvar pruritus, which can be worse at night. Clinical findings include thick, lichenified, enlarged and rugose labia, with or without edema. The skin changes can be localized or generalized. Diagnosis is based on clinical history and findings, as well as vulvar biopsy. Treatment involves a short-course of high-potency topical corticosteroids and antihistamines to control pruritus.
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A 20-year-old nulliparous college student presents with a one-month history of profuse vaginal discharge and mid-cycle vaginal spotting. She uses oral contraceptives and she thinks her irregular bleeding is due to the pill. She is sexually active and has had a new partner within the past three months. She reports no fevers or lower abdominal pain. She has otherwise been healthy. On pelvic examination, a thick yellow endocervical discharge is noted. Saline microscopy reveals multiple white blood cells, but no clue cells or trichomonads. Potassium hydroxide testing is negative. Vaginal pH is 4.0. No cervical motion tenderness or uterine/adnexal tenderness is present. Testing for gonorrhea and chlamydia is performed, but those results will not be available for several days and the student will be leaving for Europe tomorrow. Which of the following is the most appropriate treatment for this patient?
A. Metronidazole and erythromycin B. Ceftriaxone and azithromycin C. Ampicillin and doxy |
Ceftriaxone and azithromycin. Mucopurulent cervicitis (MPC) is characterized by a mucopurulent exudate visible in the endocervical canal or in an endocervical swab specimen. MPC is typically asymptomatic, but some women have an abnormal discharge or abnormal vaginal bleeding. MPC can be caused by Chlamydia trachomatis or Neisseria gonorrhoeae; however, in most cases neither organism can be isolate
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A 65-year-old G3P3 woman presents with symptoms of vaginal pressure and heaviness, which seem to worsen towards the end of the day. She has a history of three vaginal deliveries. Her surgical history is significant for hysterectomy for abnormal vaginal bleeding at age 45. On exam, she is found to have a large pelvic prolapse. Which of the following is the most appropriate initial treatment of this patient’s prolapse?
A. Sacrospinous ligament suspension B. Transvaginal tape C. Pessary fitting D. Anterior repair E. Topical vaginal estrogen |
Pessary fitting
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