NMS OBGYN

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254 terms · NMS OBGYN Q&A

A 26-year-old female presents to the ER complaining of severe RLQ pain. She is immediately taken to the OR for presumed appendicitis. At the time of her surgery her appendix is normal. The surgeon sees a large mass on the R 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. She is, by dates 6 weeks pregnant. Your main concern is:

Removing the corpus luteum will affect the pregnancy

(Pregnancy before 8 weeks of gestation depends on the corpus luteum to produce progesterone.)

A 36-year-old woman, gravida 3, para 2, at 8 weeks' gestation, presents to your clinic reporting painless vaginal bleeding. Her vital signs are: T 99.9F, BP 162/94, P 100, R 18. Her uterus is consistent with a 14-week pregnancy. Her serum hCG is 320,000 IU/L. Which endocrine gland is most likely affected by hCG?

Thyroid

(Molar pregnancy. hCG possesses TSH-like properties and can cause hyperthyroidism.)

A 29-year-old pregnant woman just found that her hCG level is elevated. Which is true?

A high level of hCG in the second trimester is the most sensitive marker for Down syndrome.

(A high level of hCG in the first trimerster is suggestive of molar pregnancy. hCG is part of the quadruple screen in the second trimester.)

Estrogens are produced by the mother, fetus, and placenta. Which one of the following is true?

Estriol is produced primarily by the placenta.

Increases myometrial gap junction function

Estriol

Suppresses maternal lymphocyte activity

Progesterone

Necessary for development of male external genitalia

hCG

Most sensitive marker for abnormal karyotype

hCG

Elevates ketone levels

hPL

Produced by the uterus

Prolactin

Inhibits lactation during pregnancy

Estriol

Lack of this hormone can cause spontaneous abortion in the first trimester

Progesterone

Lack of this hormone is associated with an enzyme deficiency in the placenta

Estriol

Elevated levels of this hormone are associated with twin pregnancy

hCG

Anecephaly causes lack of production of this hormone

Estriol

A 24-year-old woman, gravida 4, para 3, at 18 weeks' gestation dated by her last menstrual period, receives an ultrasound to confirm her "due date" and to evaluate fetal anatomy. Her first pregnancy was 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 scan the fetal ductus venosus. Using ultrasound, which structure would you see leading into and out of the ductus venosus, respectively?

Portal vein; inferior vena cava

A 37-year-old woman, gravida 1, para 1, just delivered at term a viable male infant weighing 3980 grams with APGARs of 9 and 9 at 1 and 5 minutes, respectively. 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?

Closure of foramen ovale and ductus arteriousus

The cardiac output and oxygen consumption in a fetus are approximately what multiple of that compared with an adult, respectively?

3; 3

(Fetal cardiac output is 200 mL/kg/min, whereas adult cardiac output is 70 mL/kg/min. Fetal oxygen consumption is 8 mL/kg/min, whereas adult oxygen consumption is 3 mL/kg/min.)

The most oxygenated blood is found in

Ductus venosus

Route of transfer of glucose across the placenta is

Facilitated transport

Route of transfer of iron across the placenta is

Endocytosis

Route of transfer of amino acids across the placenta is

Active transport

Route of transfer of carbon dioxide across the placenta is

Passive diffusion

Highest concentration of hemoglobin containing two alpha and two beta chains occurs during which trimester?

Third trimester

Amniotic fluid volume derived from transudation occurs during which trimester?

First trimester

Significant amniotic fluid volume contribution from the lung occurs during which trimester?

Early second trimester (weeks 14-21)

Production of red blood cells by the spleen occurs during which trimester?

First trimester

Thyroxine levels first detectable in serum occurs during which trimester?

First trimester

A 23-year-old primigravida woman just delivered an infant weighing 4350 g by spontaneous vaginal delivery. After 5 minutes of gentle traction on the umbilical cord, you deliver the intact placenta. You begin massaging the uterine fundus and ask the nurse to run 20 U of oxytocin in 1000 mL of lactated Ringer's solution as fast as possible. You notice a second-degree laceration and a 2-cm left lateral vaginal wall laceration, and brisk bleeding from above the site of laceration. Physical examination reveals a soft, boggy uterine fundus. Her vitals are: T 98.9F, BP 164/92, P 130, R 18. Which is the next best step in management?

Prostaglandin F2-alpha 0.25 mg IM

(Uterine atony is the most common cause of postpartum hemorrhage.)

Forty hours ago, a 19-year-old primigravida delivered a viable female infant weighing 3600 g. The baby's APGARs were 9 and 9 at 1 and 5 minutes, respectively. The patient is breastfeeding and reports minimal lochia. Review of her labor records reveals that her membranes were ruptured 7 hours before delivery of her infant. Her vital signs before discharge from the hospital are: T 100.8F, P 105, BP 110/70, R 16. Her physical exam is remarkable for slight tenderness in the area of the uterus; nonerythematous, nontender firm breasts; and nontender calves. Which of the following is the best initial step before treatment with antibiotics?

Urinalysis and culture

(Incomplete emptying results from excessive residual urine, overdistention, and stasis, and intermittent or Foley catheterization during labor.)

A 27-year-old woman, gravida 2, para 1, presents for her first prenatal visit after testing positive on a home pregnancy test. She reports regular cycles every 35 days. She denies use of birth control pills, Depo-Provera, or other contraceptive in the last 7 months. The first day of her last menstrual period was April 1, 2007, and the last day was April 5, 2007. She says her periods always last 4 to 5 days. What is the best estimate of her due date?

January 15

(Naegle's rule, count back 3 months and add 7 days to FDLMP, and add additional length of cycle over 28 days)

A 16-year-old primigravida presents to labor and delivery with reports of abdominal pain. Her pain is "constant" and located in both the RLQ and LLQ. There is no radiation and no associated symptoms other than constipation. The patient ate lunch a few hours ago without any problems. Her vital signs are: T 97.8F, BP 108/74, P 96, R 14. Physical exam of the abdomen reveals bilateral tenderness in the lower abdomen. There is no rebound tenderness or guarding, and costovertebral angles are nontender. Her cervix is closed and uneffaced, and 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 a WBC of 14,000/mm3. Which is the best explanation for her abdominal pain?

Round ligament

(Round ligament pain, common during the second trimester, results from stretching of the round ligaments attached to the uterus on each side and the lateral pelvic wall.)

A 20-year-old woman presents to labor and delivery 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. Ultrasound 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 flexed at the elbows. Which of the following is the fetal lie?

Complete breech

(Wrong Answer. Complete breech is the presentation. Longitudinal is the fetal lie.)

A woman presents for prenatal care. She has had two abortions, two second-trimester miscarriages, one ectopic pregnancy, a fetal demise at 37 weeks' gestation, and two live births. Her son, who is now 13-years-old, was delivered at 34 weeks' gestation by spontaneous vaginal delivery. Her daughter, who is now 10 years old, was delivered at 38 weeks' gestation by caesarian secondary to fetal distress during labor. What are her "Gs and Ps" by simple notation and FPAL notation?

G9 P3; P2142

A 34-year-old woman, gravida 2, para 1, at 32 weeks' gestation, presents for routine prenatal care. She delivered her daughter vaginally at 39 weeks without any complications. Her past medical 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 measurements are: BP 108/73, T 96.8F, fundus 33 weeks, height 5 feet 4 inches, prepregnancy weight 120 lbs, now weighs 135 lbs. She is rubella nonimmune, hepatitis B surface antigen negative, O+ / antibody -, VDRL nonreactive, and gonorrhea/chlamydia negative. What is the next best step?

Follow-up in 2 weeks

(Uncomplicated pregnancy should be seen every 4 weeks for the first 28 weeks, every 2 weeks until 36 weeks, and weekly thereafter until delivery.)

A 28-year-old woman, gravida 3, para 2, at 5 weeks' gestation, presents for confirmation of pregnancy and possible prenatal care. Her first pregnancy resulted in vaginal delivery of a viable female infant weighing 3900g at term. Her daughter has a bilateral hearing deficit. Her second pregnancy resulted in cesarian delivery of a viable male infant weighing 2900 g at 34 weeks because of pregnancy-induced hypertension. Her son was born with mild myelomeningocele. She denies family history of any diseases or problems. She tells you that she is a lacto-ovo vegetarian. What is the most appropriate advice during this prenatal session?

Increase your folic acid intake to 10 times your prepregnancy amount.

(Folic acid intake 4 mg/day during pregnancy.)

The largest contributor to weight gain during pregnancy?

Blood volume

(Contributors to weight gain during pregnancy: fetus > blood volume > uterus, lower extremity edema > amniotic fluid. Normal weight gain during pregnancy is about 30 lb.)

A 24-year-old woman, gravida 2, para 1, at 27 weeks' gestation, presents for routine prenatal care. She reports plenty of fetal movement and denies spotting or regular contractions. She does report increasing vaginal discharge that is white to yellow in color and has a distinct odor. Her temp is 98.2F, BP 100/60, fundus 28-cm. Her past medical history is remarkable for asthma (two wheezing episodes per week and symptom free nights). You perform a sterile speculum exam and notice homogenous, adherent, white-yellow discharge in the posterior fornix and the cervix, but the mucosa does not appear inflamed. The pH of the discharge is 5.5. Wet mount diplays 30% clue cells. The potassium hydrochloride (KOH) prep is nondiagnostic but has a strong odor. Which is the best diagnosis and treatment?

Bacterial vaginosis, clindamycin

A 39-year-old woman, gravida 3, para 3, is contemplating pregnancy. She delivered three healthy boys by vaginal delivery at ages 17, 23, and 27 years. Her first pregnancy was complicated by low birth weight. Her second pregnancy was unremarkable. She incurred a third-degree laceration after extension of a midline episiotomy upon delivery of her third boy. Her past medical history is unremarkable other than three to four asthma exacerbations every month. What is she at highest risk for in her subsequent pregnancy?

Twins

A 34-year-old primiparous woman is considering a second pregnancy. She is afraid to get pregnant given the outcome of her first pregnancy. At 32 years-of-age, she delivered a term infant with Down syndrome. During that gestation, a serum screen for aneuploidy was not performed. Had a second-trimester multiple marker screen been performed, which of the following results would have been helpful?

Low MSAFP, low estriol, high hCG, and high inhibin A

A 28-year-old woman, gravida 6, para 1 presents because she tested positive on her home pregnancy test. Her last menstrual period occurred 40 days ago. She normally has regular, 28-day cycles and her periods last 3-4 days. She delivered a preterm infant with her first pregnancy at age 17 years. Her subsequent pregnancies have been complicated by three miscarriages and an ectopic pregnancy. She denies any medical problems but admits contracting chlamydia during her lat teens (which she sought treatment for). Which of the following is the most important initial step?

Transvaginal ultrasound

(Woman with a history of an ectopic pregnancy and chlamydial infection who may be pregnant must have a transvaginal ultrasound to rule out another ectopic pregnancy and confirm intrauterine pregnancy.)

A 33-year-old woman, gravida 3, para 2, at 32 weeks' gestation, presents for her routine prenatal care. She delivered her first baby by cesarean due to nonreassuring fetal heart rate pattern on the fetal monitor. Her second baby was delivered by cesarean also because she did not want a trial of labor. Both infants weighed less than 4000 g and are doing fine now. Operative records of her cesarean deliveries show a Pfannenstiel skin incision and low classical type of incision of the uterus. Currently, she is interested in vaginal delivery. What is the best advice for her?

Vaginal delivery is not recommended because the risk of uterine rupture approaches 8%

(A classical uterine incision is a contraindication to a trial of labor and vaginal delivery with a subsequent pregnancy.)

A 41-year-old woman, gravida 8, para 4, at 18 weeks' gestation, presents for her first prenatal visit. She has a history of three therapeutic abortions as a teenager. She has four healthy children -- the first two delivered at 32 weeks' gestation, and her third fourth children delivered at 37 weeks' gestation. Her past medical history is significant for two episodes of pyelonephritis with her first two pregnancies, as well as a partial bicornuate uterus. What in her history places her at greatest risk for preterm delivery with this pregnancy?

Delivery history

(History of two previous preterm deliveries is the strongest risk factor for another spontaneous preterm delivery.)

A 25-year-old woman, gravida 2, para 1, at 8 weeks' gestation, presents to the high-risk clinic for prenatal care. Her first pregnancy was complicated by delivery of a premature infant with respiratory problems. Her past medical history is remarkable for severe asthma (more than 20 exacerbations per week) for which she uses albuterol and steroid inhalers. She has type II diabetes mellitus that was treated with oral hypoglycemic agents before pregnancy. She also tells you she acquired hepatitis C a few years ago when she used to inject intravenous heroine. She is 5 feet 5 inches tall and weighs 90 lb. Her BP 180/98, urine dipstick negative. Which predisposes her to delivery of an infant with congenital anomalies?

Diabetes mellitus

Which combination of markers is suggestive of Down syndrome?

Low AFP, high hCG, low estriol, high inhibin A

Which of the following canNOT be detected on a second-trimester ultrasound exam?

Tay-Sachs disease

(2nd trimester ultrasound can detect anatomic anomalies such as anencephaly, renal agenesis, two-vessel cord, tetralogy of Fallot)

A 32-year-old woman, gravida 1, para 1, comes for genetic counseling. Her first child was born with sickle cell disease. She has since remarried, and is requesting prenatal testing. Which of the following is appropriate to offer the patient first?

Paternal hemoglobin electrophoresis

Which of the following procedures poses the lowest risk for fetal loss?

Fetal echocardiography

Which of the following is NOT an indication for prenatal diagnosis?

Paternal age 45 years

(Paternal age has minimal effect on chromosomal anomalies.)

A 23-year-old woman who was seen in the emergency department yesterday for a superficial gunshot wound to the wrist tested positive on a routine serum beta-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. She denies past medical history. She does not smoke or consume any alcohol. She does take mega doses of vitamins, which include 20,000 IU of vitamin A daily. Above which dose of vitamin A has teratogenicity been noted?

8000 IU

A 28-year-old woman, gravida 2, para 1, at 11 weeks' gestation, who just moved from another state is seen for her first prenatal visit. She has an idiopathic respiratory disease that predisposes her to recurrent lung infections. She tells you that she can't even count how many radiographs she has received in the last 2 months. You contact her previous hospital's radiation biologist, who calculates her radiation exposure at approximately 260 mrad. Which of the following is the likely possible outcome of this pregnancy?

No adverse outcome

A 28-year-old woman just tested positive on a home pregnancy test even though she and her husband use condoms regularly. Her last menstrual period was 36 days ago. Her periods usually occur every 30 days. Her past medical history is unremarkable and she denies use of tobacco alcohol, or drugs. Her only concern is that 3 weeks ago she received a rubella vaccine and was told by her doctor to not become pregnant for the next 1 month after administration of the vaccine. Which of the following is the best advice?

Pregnancy outcome is usually favorable even after exposure to this vaccine.

A 19-year-old woman, gravida 1, para 0, presents to you at 7 weeks' gestation by her last menstrual period for prenatal care. Her history and physical exam are completely unremarkable. You educate her about nutrition and exercise during pregnancy and perform an in-office transvaginal ultrasound to confirm her gestational age. You then order routine prenatal labs. While chatting with her, you discover that she has a stressful job and likes to use the hot tube at least several times a day in excess of 4 hours. What is the best advice to give to this patient?

Minimize hot tube use in the first trimester because it may cause malformations

Which teratogenic agent causes persistent patent ductus arteriosus?

Rubella

Which teratogenic agent causes endocardial fibroelastosis?

Mumps

Which teratogenic agent causes triad of heart, eye, and ear defects or malformations?

Rubella

Which teratogenic agent causes skin scarring and shortened limbs?

Varicella zoster

Which teratogenic agent causes aplastic anemia?

Parvovirus

Exposure to ___ rad may have some adverse fetal effects

10

After week ___, exposure to radioactive iodine may affect fetal thyroid development.

10

Baseline risk of major congenital anomaly is ___%

3%

Intrauterine fetal growth retardation is increased ___ times in excessive drinkers

3

Infants born to epileptic mothers have ___% incidence of congenital abnormalities

6%

Rate of congenital anomalies in pregnant women taking antipsychotic medications is ___%

6%

An 18-year-old student enjoys drinking once or twice with her college friends. Lately, she has been drinking more than 10 mixed alcoholic beverages each time she goes out. Although she gets a severe "hangover" after each night of drinking, she still enjoys drinking alcohol and doesn't believe it causes any harm to her body. She is an average student at school and is able to keep a part-time job without any difficulty. She has many friends and is well liked. She claims that everybody around her drinks as much as she does. She doesn't have a thirst for alcohol throughout the day, but admits that a month ago she only had to drink four drinks to get the same "buzz" she gets now with six drinks. Her pattern of alcohol consumption is best described as

Abuse

A 30-year-old woman, gravida 2, para 1, at 8 weeks' gestation, likes to drink one glass of red wine at night with dinner and doesn't believe it will harm her developing fetus. She drank the same amount throughout her last pregnancy and she delivered a normal healthy neonate weighing 8 lb 4 oz. Her past medical history is unremarkable other than an appendectomy. When performing her ultrasound at 18 weeks' gestation, the ultrasonographer should pay close attention to the anatomy of the baby's

Heart

(There is no safe level of alcohol in pregnancy.)

A 20-year-old woman, gravida 4, para 3, presents to you at 22 weeks' gestation for routine prenatal care. She has missed her last two appointments. All of her previous pregnancies were complicated by preterm labor and delivery of small infants with significant respiratory distress. She has a history of a small inferiolateral myocardial infarct from the previous year. In the office she appears anxious. Her vital signs are: T 99.0F, BP 170/96, P 135, R 18. The rest of her physical exam is unremarkable other than what she describes as "stretch marks" on her antecubital fossa. Which obstetric complication is most likely to occur during this pregnancy?

Placental abruption

(High BP, anxiety, needle-track marks, history of preterm deliveries, and history of myocardial infarction in a young healthy woman are suspicious for cocaine use.)

A 25-year-old woman, gravida 1, para 0, at 13 weeks' gestation, presents for routine prenatal care. She says her baby moves frequently and keeps her up part of the night. She also reports increasing vaginal discharge that is odorless and otherwise asymptomatic. Upon measuring fundal height, you smell alcohol on her breath. She fails the finger-to-nose test. The rest of the physical exam is unremarkable. She has no medical history and denies smoking, alcohol, or drug use. What is the initial best step?

Confront her about your findings

A 35-year-old woman, gravida 3, para 2, at 20 weeks' gestation, is seen for a routine prenatal visit. She has no complaints. Her previous pregnancies have been unremarkable. She has chronic hypertension and a history of cholecystectomy. She has no known drug allergies. She is a successful attorney who admits to smoking marijuana several times a week for relaxation and says she has read several papers that show no increased risk of congenital anomalies. Her vitals are: T 97.9F, BP 108/68, P 100, R 16. Doppler shows fetal heart rate 156 bpm. What is best course of action during this prenatal visit?

Educate her about the possibility of delivering a small infant.

(Marijuana causes increased risk of perinatal mortality, preterm delivery, PROM, and low birth weight.)

A 25-year-old woman, gravida 2, para 1, at 36 and 4/7 weeks' gestation with a history of prior cesarean delivery, presents with abdominal pain and vaginal bleeding. She admits to using cocaine. Her vital signs are: T 99.9F, HR 120, BP 170/100. Fetal heart rate baseline is in the 160s with minimal variability and repetitive late decelerations. Her blood work is significant for a hemoglobin of 7.5, platelets of 110,000, and fibrinogen level of 250 mg/dL. The most likely diagnosis is:

Placental abruption

A 39-year-old woman, gravida 5, para 4004, presents at 38 weeks with complaints of severe headache, abdominal pain, and vaginal bleeding. Her past obstetric history is significant for an emergent cesarean section in the setting of placental abruption with her last pregnancy. Her past medical history is significant for chronic hypertension and tobacco use. Her vital signs are: P 105, BP 180/105. Her exam is significant for RUQ tenderness and a tender uterus. Her urinalysis shows 3+ protein. The following are all risk factors for placental abruption except:

History of previous cesarean section

(Risk factors for placental abruption include hypertension, history of previous placental abruption, increased maternal age, multiparity.)

A 20-year-old woman, gravida 1, para 0, at 28 weeks' gestation, arrives to labor and delivery reporting continuous vaginal bleeding and back pain. She denies sexual intercourse within the last 48 hours. She also denies trauma to the abdomen. You perform a pelvic ultrasound and note the fetus in cephalic presentation, amniotic fluid index of 10, and an anterior-fundal placenta. The fetal monitoring strip displays coupled contractions. The fetal heart rate baseline is 130 with moderate variability. Her vitals are: T 96.8F, BP 110/60, P 90, R 16. Exam reveals about 100 mL of blood in the vaginal vault. Her cervix is closed upon examination. Which of the following medications would you definitely administer?

Betamethasone

(Placental abruption management at 28 weeks requires betamethasone to decrease complications of prematurity should delivery occur.)

A 34-year-old woman, gravida 2, para 1, at 34 and 2/7 weeks' gestation, presents to labor and delivery reporting painless vaginal bleeding. You immediately perform a transvaginal ultrasound and note the placenta completely overlying the internal os, a fetus in cephalic presentation, and an amniotic fluid index of 14. The cervical length appears closed on speculum exam. Her blood pressure is 110/78 and her pulse is 106. She has slow, continuous bleeding from her vagina. Fetal monitoring reveals one uterine contraction every 30 minutes, and the fetal heart rate is reactive. What is the next best step in management?

Hospitalization

(Hospitalize until the bleeding subsides.)

A 28-year-old woman, gravida 3, para 1, at 37 weeks' gestation, presents to labor and delivery for a scheduled repeat cesarean section with possible cesarean hysterectomy. She has a history of two previous low transverse cesarean sections. The first was because of fetal distress during labor, and the second was an elective repeat cesarean section. Her current pregnancy has been complicated with complete placenta previa with occasional spotting and recent hospitalization. Delivery by low transverse cesarean section is complicated by hemorrhage and hypotension. The patient receives 20 units of packed RBCs. Which of the following organs is most likely to malfunction?

Kidney

(Also at risk for Sheehan syndrome, which is pituitary necrosis.)

A 26-year-old woman, gravida 2, para 1, at 39 weeks' gestation, is admitted to the hospital in labor with ruptured membranes. Her cervix is dilated 5 cm and is 100% effaced, and fetal vertex is at +1 station. You place a fetal scalp monitor and an intrauterine pressure catheter. Fetal monitoring strip reveals five contractions in 10 minutes, and each contraction produces 50 mmHg of pressure. Three hours later, her cervix is 5 cm dilated and 100% effaced, and fetal vertex is at +1 station. What is the next best step in management?

Cesarean section

A 22-year-old woman, gravida 1, para 0, at 40 weeks' gestation, presents to labor and delivery reporting regular contractions for the last 2 hours. She denies loss of fluid from the vagina and reports good fetal movement. Her cervix is dilated 2 cm and 50% effaced, and fetal vertex is at 0 station. The fetal monitoring strip shows regular uterine contractions every 2-3 minutes. The fetal heart rate baseline is 154 bpm without decelerations and is reactive. What is the next step in management?

Walk for 1 to 2 hours then return to check her cervix.

A 29-year-old woman, gravida 2, para 1, at 32 weeks' gestation, presents to labor and delivery reporting flank pain, fever, chills, and cramping. She is having contractions every 3-4 minutes, and the fetal heart rate baseline is 180. You check her cervix and discover a dilation of 3 cm and 100% effacement, and you see that the fetal head is floating. From the physical exam and from results of the urinalysis, you conclude that she has pyelonephritis and admit her to the hospital for intravenous antibiotics, magnesium sulfate to try to slow contractions, and steroids. Several hours later, she is having trouble breathing. Her vitals are: T 102.1F, BP 110/78, P 105, R 28, and oxygen saturation is 96% on room air. Physical exam reveals she is tachycardic but without murmurs. You hear bilateral rales over the lung bases. Her abdomen is soft, gravid, and nontender. She still has costovertebral angle tenderness. There is 2+ pedal edema. Which of the following is the most likely diagnosis?

Pulmonary edema

(Pulmonary edema is a known complication of magnesium sulfate.)

A 24-year-old woman, gravida 1, para 0, at 39 weeks' gestation, is crowning. The fetal head is not emerging from the vagina after two pushes. You palpate a thick hymenal ring of tissue at the introitus. Fetal monitoring strip shows bradycardia after the third push, so you decide to cut a 3-cm episiotomy that extends through the hymenal ring and vagina adn ends laterally in the perineum. What is the advantage of this type of episiotomy?

Avoids fourth-degree laceration

A professor of obstetrics is explaining the seven cardinal movements of labor: first--the greatest transverse diameter of the fetal head passes through the pelvic inlet; second--the fetal head descends; third--the fetal chin is brought into close contact with the fetal thorax; fourth--turning the occiput toward the 12 o'clock position; fifth--the uterine contractions extend the fetal vertex anteriorly. What is the next step?

Rotation of occiput to transverse position

A 25-year-old woman, gravida 1, para 0, at 39 weeks of gestation, has been laboring for a few hours. Her cervix is dilated to 6 cm 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 to 2 minutes at 80 mmHg of pressure and lasting 2 minutes. Fetal heart rate baseline by scalp electrode is 90 bpm for the last 2 minutes (FHR baseline 30 minutes ago was 140 bpm). What is the best next step in management?

Discontinue oxytocin

A 27-year-old woman, gravida 1, para 0, at 40 and 3/7 weeks' gestation, is in the middle of the first stage of labor. Her cervix is dilated to 4 cm and a decision has been made to place an epidural. Prior to placement of the epidural, she receives a 500-mL bolus of lactated Ringer's to prehydrate her, and augmentation with oxytocin is begun. Her vitals are: T 99.1F, BP 110/74, P 102, R 18. The fetal heart rate baseline is 142 bpm with three accelerations every 20 minutes. She is contracting every 3 minutes. After placement of the epidural, fetal heart rate baseline drops to 130 bpm, and no accelerations are seen within a 10-minute period. The fetal heart rate also shows a gradual decline in the middle of each contraction to about 115 bpm and then returns to baseline of 130 bpm. She has contractions every 2 to 3 minutes now. Her vitals at this point are: T 99.2F, BP 78/56, P 115, R 18. What is the best next step in management?

Ephedrine

(To prevent hypotension from epidural blockade, anesthesiologists hydrate patients before placement of the epidural and then give ephedrine to keep the BP near baseline.)

A 22-year-old woman, gravida 2, para 1, at 41 weeks' gestation, is laboring. Her cervix is dilated to 8 cm and 100% effaced, and fetal vertex is at +1 station. Membranes have been ruptured for more than 24 hours, and labor is being augmented with oxytocin. An amnioinfusion is running because of 3-4+ meconium. Fetal heart rate by scalp electrode has a baseline of 138 bpm with reduced short-term variability and occasional mild variable decelerations. You are suddenly called to evaluate a nonreasuring fetal heart rate. The tocodynamometer shows six contractions in a 10-minute period with a pressure of 70 mmHg, and fetal heart rate is now 70 bpm for more than 3 minutes. She is placed in the left lateral position, oxytocin infusion is stopped, she is given oxygen by mask, and her intravenous fluid rate is increased. Fetal heart rate is now 98 bpm. What is the best next step in management?

Terbutaline

A 19-year-old woman, gravida 1, para 0, at 38 weeks' gestation, is in active labor. Her cervix is dilated to 5 cm and fetal vertex is at +1 station. The tocodynamometer displays contractions every 2 to 3 minutes, lasting 1 minute, and producing 50 mmHg of pressure inside the uterus. The fetal heart rate by scalp electrode has a baseline of 140 bpm with random sharp decelerations to 70 bpm that returns to baseline in 60 to 80 seconds. When this type of deceleration occurs, what is the best description of the initial acid-base status of the fetus?

Respiratory acidosis

A 26-year-old woman, gravida 2, para 1, at 20 weeks' gestation, seen for prenatal care. Her fundus measures 18 weeks and you are unable to hear fetal heart tone by Doppler. You perform an ultrasound and confirm lack of fetal heart activity and lack of fetal movement. Her last pregnancy was complicated by severe preeclampsia at 34 weeks that forced her to deliver a preterm baby. She has no medical problems other than mild asthma. Upon further inquiry she tells you she had one episode of spotting 4 weeks ago but did not have cramping nor did she pass any clots or tissue from the vagina. Which of the following is the most descriptive diagnosis?

Missed abortion

Chromosomal abnormalities account for the majority of first-trimester spontaneous abortions. If one was to analyze the chromosomal composition of the products of conception that are extruded in a spontaneous abortion, which of the following would be the most common finding?

Trisomy

(Trisomy 16)

A 30-year-old woman, gravida 4, para 3, at 12 weeks' gestation, is seen for prenatal care. Her first pregnancy ended with a successful vaginal delivery, at term, of a health boy. Her second pregnancy was uncomplicated and resulted in a cesarean section with low transverse incision of uterus for breech presentation after failed external version. Her last pregnancy resulted in the successful "natural" birth of her daughter. What is the best advice you can give this patient regarding vaginal birth after cesarean section (VBAC)?

You are an excellent candidate for VBAC

You are an attending obstetrician in charge of a busy hospital. You are monitoring the progress of a woman (gravida 2, para 0) who has been in labor for the past 24 hours; her membranes have been ruptured for 17 hours. Three hours ago, her cervix was 10 cm dilated and 100% effaced. The fetal vertex had reached the pelvic floor and was in the left occiput anterior position. She has an epidural. The fetal heart rate tracing was reassuring, and she began pushing. Now, the fetal vertex has reached +2 station though the fetal vertex feel asynclitic. Given her protracted second stage of labor, you decide to perform a forceps delivery. What step is NOT necessary prior to proceeding?

An additional obstetrician in the room

(Requirements for forceps delivery include: adequate anesthesia, completely dilated cervix, ruptured membranes, and confirmation of fetal head position.)

Risk of sensitization in Rh-negative woman after D&E if RhoGAM not given

0-10%

Risk of uterine perforation after D&E

0-10%

After three spontaneous abortion (SABs), risk of SAB if no history of liveborn

35-45%

Annual percent of births by cesarean section in the United States

25-30%

Risk of endomyometritis after cesarean section

35-45%

Uterine atony as the indication for cesarean hysterectomy

35-45%

Success rate for VBAC after one previous low transverse cesarean section for fetal distress and two previous successful VBACs

71-80%

A 24-year-old parturient is at 20 weeks' gestation. Her past medical history is notable for mitral stenosis secondary to rheumatic heart disease as a child. What physiologic changes places her at risk for the development of heart failure during her pregnancy?

Increase in stroke volume

A parturient at 40 weeks' gestation is scheduled for a magnetic resonance imaging scan to assess for placenta accreta. The radiologist is unable to complete the study due to nausea whenever the patient is supine. What do you recommend to the radiologist?

Tilting the patient to the left

A 24-year-old parturient with severe preeclampsia requires urgent cesarean delivery for nonreassuring fetal heart rate. The anesthesiologist plans general anesthesia. Which of the following maneuvers would you recommend to increase the safety for airway management in this patient?

Have small-diameter endotracheal tubes available

A 28-year-old parturient at 40 weeks' gestation requires general anesthesia for cesarean delivery due to umbilical cord prolapse. With induction of anesthesia, there is a rapid decline of the oxygen saturation. This decline is a result of a decrease in which lung volume?

Residual

The pain of the second stage of labor is conveyed by which nerve?

Pudendal

A 25-year-old woman requires cesarean section during epidural anesthesia. Prior to the injection of local anesthetic, the anesthesiologist administers a test dose of 3 mL lidocaine 1.5% with epinephrine 1:200,000. The patient complains of tinnitus and a rapid heart rate. What is the most likely etiology of her symptoms?

Intravascular injection

A 24-year-old parturient at 40 weeks' gestation is in active labor and requests epidural analgesia. During epidural placement, the dura is punctured. The patient is at increased risk for the development of which of the following complications postoperatively?

Headache

A 21-year-old parturient is considering epidural analgesia. Which of the following is increased in patients with epidural analgesia?

Prolonged labor

A 33-year-old woman, gravida 2, para 1, who is in the third trimester presents for her first prenatal care. She is not sure of her due date because she has been given three different dates by three different doctors. She tells you that her periods are irregular and occur every 21 to 35 days. She has not taken any form of birth control for the past 2 years. The first day of her last menstrual period was July 19, 2006. You obtain a record of an ultrasound performed in the emergency room on September 5, 2007, which showed her to be at 8 0/7 weeks of gestation. You also obtain a record from her last doctor who performed an ultrasound on December 22, 2007, which showed her to be at 24 3/7 weeks of gestation. Which one of the following is the best estimate of her due date?

April 19, 2008

A 22-year-old woman, gravida 1, para 0, at 15 weeks' gestation by her last menstrual period, presents for an ultrasound exam to confirm her due date. Which of the following measurements on the fetus is the best at predicting her actual due date?

Biparietal diameter

A 25-year-old woman, gravida 3, para 0, at 42 weeks' gestation, presents for prenatal care. She has accurate dating and has been receiving twice-weekly NSTs for the last week. Underdevelopment of which structure in the fetus may contribute to prolongation of this woman's gestation?

Adrenal cortex

A 34-year-old, gravida 3, para 1, abortions 1, at 42 1/7 weeks' gestation by a week-6 ultrasound, presents to your clinic. Her NST is reactive and amniotic fluid volume (AFV) is 8.5. Her cervix is 0.5 cm dilated, 20% effaced, midposition, and firm, and the fetal vertex is at -4 station. Which of the following is the best next step in management?

Prostaglandin analog

(At 42 weeks, prostaglandins will "ripen" the cervix for induction.)

A 25-year-old woman, gravida 3, para 2, comes to labor and delivery at 30 weeks' gestation complaining for regular uterine contractions. Cervical exam reveals 3-cm dilation and 80% effacement. The patient is administered corticosteroids and tocolytics. The contractions persist despite adding a second tocolytic agent and the obstetrician proceeds with amniocentesis. The amniotic fluid findings reveal presence of bacteria on Gram stain. The next best step is:

Discontinue the tocolytic therapy

A 28-year-old woman, gravida 3, para 2, at 28 weeks' gestation, has been admitted to the hospital for several days to treat her preterm labor. Her cervix was dilated to 3-cm and 100% effaced when MgSO4 was started at 2.5 g/hr after a bolus over 30 minutes. An entire workup for preterm labor was done, and she received antibiotics and steroids. Currently, she has three to four contractions per minute that she barely feels on 2 g/hr. Treatment with MgSO4 is most likely to:

Delay delivery for 2 days

A 22-year-old woman, gravida 1, para 0, at 33 weeks' gestation, presents to labor and delivery and reports cramping and lower back pain. She denies leaking fluid from the vagina. You perform a speculum exam that shows no pooling, and Nitrazine paper stays yellow after contact with the secretions in the posterior fornix. Cervical cultures are taken. She is placed on fetal heart rate and uterine contraciton monitoring, which shows a baseline heart rate of 155 beats per minute and three uterine contractions per a 10-minute period. Her cervix changes from closed and 50% effaced to 2 to 3 cm and 80% effaced. The next best step in management of this patient is:

Corticosteroids and tocolytic therapy

A 29-year-old woman, gravida 3, para 1, spontaneous abortions 1, at 30 weeks' gestation, is in preterm labor. She has received an initial bolus of 6 g of MgSO4 over 30 minutes, and she has been placed on a maintenance rate of 4 g/hr for the last 2 days to reduce her contraction pattern to one every 15 minutes (her contractions are barely noticeable to her). Currently, her vitals are: P 88, BP 90/50, R 9, SaO2 95% on room air. Her deep tendon reflexes are 0 bilaterally. She has crackles on her lung bases on deep inspiration. The next best step in management is

Discontinue MgSO4

You have been seeing a 23-year-old woman, gravida 1, para 0, at 28 weeks' gestation, throughout her pregnancy. She has no known medical history. She denies blurry vision, epigastric or RUQ pain, severe headache, or trouble breathing. Her blood pressure and urine protein dipstick results for the past three visits are: visit#1, BP 120/75, U(dip)=0; visit#2, BP 110/65, U(dip)=1+; visit#3, BP 115/68, U(dip)=1+. Today her BP 120/75, U(dip)=trace. She reports lots of fetal movement. Her fundus measures 25 cm. Lungs are clear to auscultation bilaterally. Deep tendon reflexes are 2+ symmetric. Results from laboratory studies you sent on visit 3 are: AST 340 U/L, ALT 200 U/L.
The most accurate diagnosis for this patient is:

Severe preeclampsia

A 20-year-old primigravid woman at 37 weeks' gestation (confirmed by a first-trimester ultrasound) presents to the clinic for routine prenatal care. She reports active fetal movement and abdominal pain. Her blood pressure is 162/103 initially and she has 2+ protein on the urine dipstick. Her physical exam is unremarkable except for diffuse tenderness on the abdomen; however, there is no rebound tenderness. Her fundus measures 36-cm. You send for CBC, liver enzymes, electrolytes, uric acid, urinalysis, and coagulation profile. On labor and delivery, her blood pressure is 166/104 and there is 3+ proteinuria on urine dipstick. Her cervix is closed, long, firm, and posterior, and fetal vertex is high. What is the next step in management?

Prostaglandin analog and magnesium sulfate

A 26-year-old primigravida at 35 weeks' gestation complains of mild headache and facial edema. Her blood pressure is 160/100 and her reflexes are brisk. You suspect that she has preeclampsia. Her urinalysis is likely to show which of the following?

Proteinuria

The diagnosis of preeclampsia would be advanced to eclampsia if the woman developed which of the following?

Grand mal seizures

A 38-year-old African-American woman, gravida 1, presents for a routine visit at 39 weeks' gestation. Her blood pressure is persistently 140/90 mmHg, and her urine protein is 2+. Physical exam is otherwise unremarkable, and she is completely asymptomatic. Her cervix is 2-cm dilated and 90% effaced, with the fetal vertex at 0 station. The most appropriate management is:

Induction of labor

A 25-year-old Asian woman, gravida 2, para 0, presents at 33 weeks' gestation for a routine visit. Her blood pressure is 150/100 mmHg, and her urine protein is 3+. Physical exam is otherwise unremarkable. She reports mild headache, but no RUQ pain or visual scotomata. The most appropriate management is:

Admission to hospital

A 26-year-old nurse, gravida 2, para 1, at 32 weeks' gestation, presents to labor and delivery because of elevated blood pressures. She says her systolic blood pressures have been in the high 170s and her diastolic blood pressures have been in the low 110s. She denies abdominal pain, visual disturbances, or severe headaches. Her blood pressure at L&D is 150/98 and she has 1+ proteinuria. You send off appropriate labs, admit the patient to the hospital, and keep her on bedrest. Which of the following is an appropriate next step in management?

Betamethasone

A 35-year-old woman, gravida 5, para 1, at 6 weeks' gestation, is seen because she just found out she is pregnant. She has a 6-year history of essential hypertension controlled on a diuretic agent. After you perform a routine prenatal exam, you change her blood pressure medication to methyldopa and ask her to use it throughout the entire pregnancy. Which of the following is the best reason for using methydopa in a patient with chronic hypertension during pregnancy?

It decreases the risk of maternal end-organ damage

Which of the following is an independent risk factor for pregnancy-induced hypertension?

Age older than 40 years

Which of the following might be found in a patient with MILD preeclampsia?

Proteinuria in excess of 3 g per 24 hours

A 24-year-old primigravida is seen 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 now and has been on oral medications for blood sugar control. Her capillary blood glucose level is 110 mg/dL today. After delivery, her newborn will be at risk for:

Low calcium (hypocalcemia)

A 22-year-old woman, gravida 2, para 0, at 22 weeks' gestation, presents for her routine prenatal visit. She has been seeing you throughout her pregnancy. She had diabetes prior to becoming pregnant and was taking an oral hypoglycemic agent to control her blood sugars. However, since becoming pregnant, she has been self-administering daily regular and NPH (neutral protamine Hagedorn's) insulin. Today, she reports lower back discomfort. Her fundus measures 21-cm and she has 1+ glucose on urine dipstick. Her average fasting blood sugar is 93 mg/dL, and her 2-hour postprandial sugar is 119 mg/dL. What is the next step in management of this patient?

Perform fetal echocardiograph

A 28-year-old woman, gravida 2, para 1, at 20 weeks' gestation, presents with increased sweating and palpitations. Her fundus measures 17-cm. T 98.8F, 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 step in management of this patient?

Propranolol

(Propranolol is the initial treatment for palpitations and tachycardia from hyperthyroidism.)

An 18-year-old woman, gravida 3, para 2, at 28 weeks' gestation, is admitted with right-sided back pain, fever, chills, and severe nausea. She has bilateral costovertebral angle tenderness, with greater discomfort on the right side. T 102.6F, with normal CBC, BUN, and creatinine. Urinalysis revealed more than 100 WBC/hpf. After 3 days of culture-appropriate antibiotics, her temperature is still 103F. The next step is:

Perform an ultrasound

(Renal ultrasound to rule out an abscess or renal calculi.)

A 20-year-old woman just delivered a viable male neonate at 38 weeks' gestation after being a restrained passenger in a car accident. Upon arriving at the emergency department she was "cleared" by the trauma and orthopedic teams and sent to the labor and delivery floor. There she began having vaginal bleeding and then went into labor spontaneously. The estimated blood loss with delivery was 900 mL, and now she is stable. After obtaining her prenatal information you realize she is Rh negative and antibody D negative. The next step is:

Assess neonatal Rh antigen status

A 24-year-old woman, gravida 1, para 0, at 24 weeks' gestation by her last menstrual period, presents to the emergency department because of vaginal bleeding. T 97.8, BP 135/88, P 105, R 16. Her fundus is below the umbilicus and there are no fetal heart tones on Doppler. On speculum exam you see blood emerging from an undilated external os, but no lesions are seen on the cervix or the vaginal walls. Her quantitative hCG level is 85,000 mIU/mL. You are awaiting a formal ultrasound by a radiologist to confirm your suspicion of a molar pregnancy. What is the most likely explanation for this scenario?

Maternal X + Paternal X + Paternal X

(Incomplete molar pregnancy: uterus is smaller than dates, normal ovum is fertilized by two sperm, fetal tissues are present.)

A 24-year-old woman, gravida 1, para 0, at 24 weeks' gestation by her last menstrual period, presents to the emergency department because of vaginal bleeding. T 97.8, BP 135/88, P 105, R 16. Her fundus is below the umbilicus and there are no fetal heart tones on Doppler. On speculum exam you see blood emerging from an undilated external os, but no lesions are seen on the cervix or the vaginal walls. Her quantitative hCG level is 85,000 mIU/mL. You are awaiting a formal ultrasound by a radiologist to confirm your suspicion of a molar pregnancy. Which of the following findings is the most likely on pelvic ultrasound exam?

Two-vessel umbilical cord

(Incomplete molar pregnancy)

A 33-year-old woman, gravida 4, para 3, at 16 weeks' gestation by her last menstrual period, presents to labor and delivery complaining of vaginal bleeding. Her vital signs are: T 98.9F, BP 150/94, P 103. Fundal height measures 23-cm. A pelvic ultrasound exam reveals a uterus with a diffuse indistinct mass filling the endometrial cavity, and no fetal parts are seen. A dilation and suction curettage is performed and 10 minutes afterwards she is placed on a dilute intravenous oxytocin drip. Complications involving which one of the following organs are most likely to occur at this time?

Lung

(Following D&C of a molar pregnancy, the lungs can be injured by emboli from trophoblastic tissue, fluid overload, or thyroid storm.)

A 27-year-old nulliparous woman presents to the emergency room reporting hemoptysis. She has no medical history other than a pregnancy 3 months ago that resulted in spontaneous abortion. She also has had intermittent vaginal spotting since the miscarriage. Her BP 110/70 and P 88. Significant labs are Hg 9.6 mg/dL and quantitative beta-hCG 35,000 mIU/mL. Her chest radiograph shows several masses in the right middle lobe. Which of the following is the best treatment option for her?

Methotrexate and leucovorin

A 36-year-old multiparous woman just underwent a hysterectomy because of a molar pregnancy. Other than her treatment for gestational trophoblastic disease, she has no medical problems. She had an appendectomy 3 years ago. She is allergic to penicillin and, although she does not smoke, she admits to drinking at least three to four alcoholic beverages per day. You obtain a beta-hCG 2 days after the operation. What is the next best step in management of this patient?

beta-hCG in 1 week

(Following treatment of a molar pregnancy, the patient needs a 48-hour hCG level, then weekly hCG until the results are negative three times, then every month for 6 months, and then annually.)

A 24-year-old woman, gravida 1, para 1, is seen because every month since age 19 she has had severe lower pelvic pain during her periods. She says the pain is similar to "labor pains" and it interferes with her ability to concentrate at work and during leisure activities on the weekends. Her pain has also caused her to become extremely anxious and irritable. She has tried acetaminophen with little relief. She denies having a depressed mood or changes in sleep, energy, or eating patterns. Her past medical history is remarkable for mild asthma controlled with albuterol. She is sexually active, is in a monogamous relationship, and uses condoms for contraception. She has no known drug allergies but admits to drinking a few alcoholic beverages every day. The next step for this woman is:

Ibuprofen

(Best treatment for dysmenorrhea is NSAIDs (eg ibuprofen).)

Two female medical students are having a discussion about ovarian reserve. Medical student #1 claims that because women are born with a finite number of follicles and because she has been taking birth control pills since age 16, she has slowed down loss of her follicles every month by inhibiting ovulation. Medical student #2 claims that because she has been pregnant more times than medical student #1, she has a higher ovarian follicle reserve. Which of the following statements is true?

There is no way to slow down depletion of eggs.

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 hormones X, Y, and Z respectively?

Estrogen, inhibin A, and LH

Many infertility patients undergo in vitro fertilization (IVF) and embryo transfer (ET) in order to become pregnant. IVF-ET uses many of the principles of the normal menstrual cycle to achieve pregnancy. The patients are given FSH hormone to stimulate multifollicular development, just as occurs in the normal menstrual cycle. Human chorionic gonadotropin is used to "trigger" the ovulation process because it is an analog of LH hormone. Supplemental progesterone is given after the oocytes are retrieved to support the endometrium for implantation. Multiple follicles develop because:

There is excess FSH available

A 24-year-old nulligravid woman presents because of amenorrhea of 4 months' duration. She was started on birth control pills at age 18 due to irregular menses. She continued the pills until 4 months ago when she was in a terrible motorcycle accident and had to undergo multiple surgeries on her face to repair fractures. Her past medical and surgical history is unremarkable. Her physical exam is normal. You obtain labs, which reveal the following: hCG less than 5 mIU/mL, prolactin 12, TSH 2.2, FSH 67, estradiol less than 30 pg/mL. Which one of the following is the most likely diagnosis?

Turner syndrome

(Most common cause of secondary amenorrhea is Turner syndrome.)

An 18-year-old nulligravid female is seen because she has not had a period for the last 8 months. She is a freshman in college majoring in dance. She enjoys hiking to relieve stress. 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 feet 8 inches tall and weighs 90 lb. Her vital signs are: T 96.6F, BP 108/60, P 52. On exam, she has a normal-appearing vulva and appropriate-sized vagina without any lesions. Her cervix and uterus are unremarkable. You do not appreciate any adnexal masses or tenderness. The rest of her physical exam is unremarkable other than her teeth, on which you see erosion of the upper and lower incisors, especially posteriorly. She also has small scars on the back of her hands. the most likely hormone abnormality in this patient is:

Decreased FSH

(Anorexia nervosa causes decreased gonadotropins (FSH and LH) and low estrogen, but normal free T4, TSH, and prolactin.)

A 25-year-old nulligravid female presents because she has not had a period for the last year. She didn't think too much of it initially due to her hectic schedule, but is concerned now because she recently stated a serious relationship. Although she admits she is not yet ready to become pregnant, she wants to have regular periods. She has no significant medical or surgical history. She started her periods at age 12 and they became regular at age 14 until last year. She has never had a major illness. She has no known allergies to medications. She is a major bank executive who travels across the United States and Europe often. She runs 5 miles a day and uses a Jacuzzi often to relax. Her vital signs are: T 98.9F, BP 135/86, P 100. Her physical exam reveals a height of 5 feet 6 inches and weight 132 lb. The rest of her exam is unremarkable. Labs are: TSH 1.7, prolactin 11, FSH 5.0, estradiol 45. Abnormality of which structure most likely accounts for her amenorrhea?

Hypothalamus

(Any excessive stress changes neurotransmission in the hypothalamus.)

A 25-year-old nulligravid female presents because she has not had a period for the last year. She didn't think too much of it initially due to her hectic schedule, but is concerned now because she recently stated a serious relationship. Although she admits she is not yet ready to become pregnant, she wants to have regular periods. She is a major bank executive who travels across the United States and Europe often. She runs 5 miles a day and uses a Jacuzzi often to relax. The best next step in management of this patient is:

Norgestimate and ethinyl estradiol

(Optimal treatment of hypogonadotropic amenorrhea is either hormone replacement therapy or birth control pills. Since this patient is not ready to become pregnant, birth control pills are more reasonable.)

A 16-year-old presents because she has never had a period. She has no past medical or surgical history. She has never had a major illness. She has no known drug allergies. She is a senior in high school and has been accepted to an Ivy League university. In addition to her excellent academic performance, she is active as a volunteer in the community and enjoys tennis and volleyball. She is 5 feet 7 inches tall and weighs 125 lb. Her vital signs are: T 98.7F, BP 110/70, P 70. Her abdomen is unremarkable. She has Tanner stage 4 breast development, axillary hair growth, and pubic hair growth onto her thighs. On sterile speculum exam you discover a short vagina that ends blindly. The diagnosis is:

Mayer-Rokitansky-Kuster-Hauser syndrome

(Most common disorder of the outflow tract.)

A 21-year-old nulliparous woman reports several years of irregular menses, occurring only four to five times a year. On physical exam you notice hair on her neck, chin, upper lip, and lower abdomen. Your laboratory workup of this patient include all of the following EXCEPT:

Lutienizing hormone/ follicle-stimulating hormone

(Workup for PCOS includes TSH, serum testosterone, 17-OH progesterone, and prolactin.)

A 17-year-old woman complains of increased hair growth over the past 6 months, requiring her to wax her upper lip and chin. Her menses have been irregular. Laboratory testing suggests she has PCOS. What is the best recommendation for treating excess hair growth?

Combined hormonal contraceptive, antiandrogen, and laser or electrolysis

An obese 38-year-old woman complains of several episodes of irregular vaginal spotting throughout the past 6 months. She has a long history of irregular periods and was diagnosed with PCOS as a teenager. 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:

Endometrial biopsy

(A woman over 35-year-old with history of irregular menses is at increased risk of endometrial hyperplasia and endometrial cancer.)

A 27-year-old obese nulliparous woman has been on oral contraceptives since age 16 for irregular periods. She comes to you becomes she 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 that her weight may be a problem. You counsel that:

If she lost weight, she may start to have periods on her own

(Obesity compounds the effects of PCOS and causes problems during pregnancy.)

A 32-year-old female, gravida 0, presents with her husband because they want to conceive. She has PCOS diagnosed by you 14 years ago and has been maintained on oral contraceptives and antiandrogens since then. She stopped those medications and started prenatal vitamins as per your instructions 4 months ago and has not had a period since. Her pregnancy test is negative. At this point you would recommend which one of the following approaches to help her achieve a pregnancy?

Clomiphene citrate

(Clomiphene citrate is the first-line medication to induce ovulation.)

Which hormone/substance/enzyme is most likely to account for rapidly progressive hirsutism?

Androstenedione

Which hormone/substance/enzyme is most likely to account for hirsutism in a woman with regular menses and no abnormal hormonal measurements?

5alpha-reductase

Which hormone/substance/enzyme is most likely to account for hyperplasia of adrenal gland as source of androgen excess?

17-hydroxyprogesterone

A 33-year-old woman, gravida 2, para 1, spontaneous abortions 1, reports increasing dark hair growth on her chin, upper lip, and lower abdomen. This growth has occurred over many years and has forced her to wax and bleach more often. She denies changes in her voice or size of her clitoris, reduction in breast size, or acne. During her early teen years, she had regular menstrual periods that lasted 4 to 5 days. Now, however, she has to take birth control pills to regulate her cycles. Her past medical history is significant for hepatitis C, which she acquired from a blood transfusion to treat postpartum hemorrhage with her first pregnancy. The next best step in the management of hirsutism in this patient is:

Spironolactone

(Spironolactone is an androgen receptor blocker and 5(alpha)-reductase inhibitor, thus preventing DHT binding and production respectively.)

A 23-year-old woman, gravida 1, para 0, abortion 1, has irregular, unpredictable menstrual periods every 30 to 90 days. Physical exam reveals acne on her face and back and several dark, coarse hairs on her chin and lower abdomen. The initial step in diagnosis of androgen excess in this woman is to measure which of the following?

17-hydroxyprogesterone

(Diagnosis of PCOS requires exclusion of other causes of hyperandrogenism, including nonclassic adrenal hyperplasia (NCAH) by measuring 17-hydroxyprogesterone level.)

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