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NMS OBGYN

NMS OBGYN Q&A
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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.)
A 22-year-old African-American female complains of severe hirsutism on her face. She is currently shaving daily and is very distressed. After you evaluate her you diagnose PCOS. You give her what advice for the best way to manage her hirsutism symptoms?
Combined hormonal contraception with spironolactone is the best option
A 50-year-old woman, gravida 3, para 2, spontaneous abortions 1, reports abnormal vaginal bleeding. Her menstrual cycles used to occur regularly every 30 days for the last 6 months. She denies any past medical or surgical history. Review of systems is negative and she specifically denies lightheadedness. Her speculum exam is unremarkable. The bimanual exam reveals a slightly enlarged, regular contour, anteverted uterus that is nontender to palpation. The next best step in management is:
Endometrial biopsy

(Women over age 40 years with abnormal uterine bleeding should be evaluated for endometrial carcinoma.)
A 14-year-old nulligravid girl reports menstrual bleeding every 45 to 50 days and bleeding for 4 days. She experienced menarche at age 13. She is not sexually active. Her physical exam is unremarkable, and her serum pregnancy test is negative. The next best step in management is:
Reassurance

(Irregular bleeding following menarche should evolve into a pattern of regular bleeding by 2 years from menarche.)
A 32-year-old woman, gravida 1, para 1, reports bleeding between her periods and lengthening of the time between her periods to more than 40 days. Review of systems is remarkable for a 70-lb weight gain since her pregnancy 2 years ago. She denies any medical problems. She is 5 feet 4 inches tall and weighs 230 lb. Her physical exam is otherwise unremarkable. The most likely explanation for her bleeding is:
Increased endogenous estrogen

(Adipose tissue contains 5(alpha)-reductase that synthesizes estrogen.)
An 18-year-old nulligravid girl presents to the emergency department by ambulance because she passed out on the floor of her house and is covered in blood. She is now conscious. She has been bleeding off and on for the past 5 months. Her BP 98/48, P 120, R 16, T 96.2F. Her speculum exam reveals blood trickling from the cervical os. There are no lesions in the vagina or cervix. The bimanual exam is unremarkable. Pelvic ultrasound is also unremarkable. Serum hCG is negative, and her Hemoglobin 7 g/dL. The next best step in managment of this patient is:
Low-dose combination oral contraceptive pills

(Low-dose oral contraceptive given as three pills a day with taper over 3-4 days is an effective way to stop dysfunctional bleeding quickly in a stable patient.)
A 25-year-old woman, gravida 4, para 4, with a history of leiomomas, presents to the emergency room reporting pelvic pressure. She denies cardiac, renal, or hepatic symptoms. A pelvic ultrasound shows a 10-cm left uterine mass that has the echogenicity of a fibroid. Pressure from the fibroid may also cause:
Varicose veins
A 30-year-old woman, gravida 2, para 2, presents to you for her annual gynecologic visit. Currently, she has no symptoms. You perform a Pap smear and a pelvic exam that reveals an enlarged, nontender, irregular uterus and no adnexal mass or tenderness. There are no vulvar or vaginal lesions. The most likely type of fibroid is a:
Subserosal pedunculated fibroid (7-cm size)
A 22-year-old woman, gravida 2, para 1, at 20 weeks' gestation, presents to the emergency department reporting acute-onset lower abdominal pain. She has a history of fibroids and an unknown abdominal surgery. Her vital signs are: T 99.2F, BP 105/68, P 110, R 28. There is a linear, 4-cm scar in the RLQ, bowel sounds are present, and the abdomen is nontender except for spot tenderness in the midline, between the umbilicus and the symphysis pubis. There is no rebound tenderness or guarding. There is no costovertebral angle tenderness. Her fundus is 28-cm. Her WBC is elevated, urinalysis is normal, and liver function tests are normal. The most likely diagnosis is:
Leiomyomatous degeneration
A 27-year-old woman, gravida 2, para 1, at 30 weeks' gestation, presents to the clinic for a routine prenatal visit. Her pregnancy has been unremarkable thus far. "Serosal fibroids" are listed under her "problem list." Her fundus measures 37-cm. In discussing possible complications of a fibroid uterus during pregnancy, you mention that she is at highest risk for:
Breech presentation
A 49-year-old woman, gravida 3, para 2, spontaneous abortions 1, who has a known myomatous uterus presents because of heavy bleeding during her periods and occasional spotting in between her periods. Her menses occurs every 5 to 6 weeks and lasts 6 to 10 days. It is associated with painful cramps. She has no chronic medical problems. The next best step in management of 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 34-year-old woman, gravida 0, has been trying to get pregnant for the last 3 years and has been unsuccessful. 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 but normal-sized uterus, and right adnexal mass. A recent pelvic ultrasound reveals a 6-cm right complex ovarian mass. Her CA -125 is elvated. What is the initial next step in management?
Laparoscopy with cystectomy
A 23-year-old woman, gravida 1, para 1, reports lower abdominal pain of 1 year's duration. She says that the pain is constant and dull and is worse around the time of her periods. She has no significant medical history and is taking birth control pills for contraception. 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 management?
Oral contraceptive therapy
Which of the following patients is unlikely to have endometriosis?
A 28-year-old with menorrhagia and a 4-cm submucosal myoma

(Myomas are benign proliferations of uterine smooth muscle.)
What blocks production of estrogen within the endometriosis implant?
Aromatase inhibitor
Patient with red hemorrhagic vesicles and white lesions who has a pelvic peritoneal defect on laparoscopy
Allen-Master lesion
Reason why naproxen may alleviate pain symptoms in a patient with endometriosis
Prostaglandins
Complication of extraperitoneal endometriosis
Prostaglandins
A 32-year-old woman, gravida 2, para 2, reports chronic abdominal and pelvic pain. The pain is intermittent, 6/10 intensity, worse when she lies on her left side, and nonradiating, and occurs at different times throughout her menstrual cycle. Her past medical history is uneventful other than an appendectomy 4 years ago for a ruptured appendicitis. On physical exam of the abdomen in the supine position, you note a small linear scar in the RLQ and active bowel sounds. The abdomen is diffusely tender to palpation, especially in the lower quadrants, and you do not palpate any masses. Her pelvic exam is unremarkable. The most likely diagnosis is:
Adhesive disease
A 19-year-old female, gravida 0, has had increasingly severe menstrual cramps since menarche. Her pain is worse around the time of her menses, but she also complains of dyspareunia, and the pain is worse with movement. She denies any nausea or vomiting, diarrhea, or constipation. She is otherwise healthy and denies any prior surgery. The cause of her pelvic pain is most likely to be:
Gencologic, urologic, or musculoskeletal
An 18-year-old nulligravid woman presents with painful periods. She says she only has pain during the first 2 days of her periods, which are regular. The pain is always midline and 2-cm below the level of the umbilicus. She says Motrin helps ease the pain. She has no other medical or surgical history. Her pain is transmitted via:
Sympathetic fibers to T11
A 33-year-old woman, gravida 5, para 4, therapeutic abortion (TAB) 1, presents with LLQ pain for 2 days. She describes the pain as intermittent initially but now constant, 7/10 intensity, nonradiating, and not associated with any other symptoms. Her last menstrual period was 2 months ago. She had a tubal ligation 3 years ago and a cholecystectomy 7 years ago. Her physical exam is: T 98.5F, BP 118/76, P 89, R 18. Abdominal exam reveals a sar on the RUQ and a small scar within the umbilicus and RLQ, present bowel sounds, slight tenderness to palpation in the LLQ, but no rebound tenderness and no guarding. Her pelvic exam reveals a uterus of normal size, shape, and contour, and no adnexal masses are appreciated. What is the next best step in management?
Serum beta-hCG
A 25-year-old woman, gravida 4, para 3, spontaneous abortions 1, presents for the first time reporting pelvic pain. She has had this pain for the last 10 years and has seen several physicians. She describes the pain as continuous and dull (4/10 intensity) with intermittent exacerbations (10/10). The pain occasionally radiates to her lower back and down her thighs. Nothing she takes or does seem to help her. The pain is not related to her menstrual cycle, which occurs only a few times a year. She has dyspareunia. She has a past medical history significant for asthma, peptic ulcer disease, and major depression. She has had a postpartum bilateral tubal ligation. She has had three hospitalizations within the last 10 years for suicide attempts. She also has a history of sexual abuse by a close family relative that occurred when she was 13 years old. Currently, she is using an albuterol metered dose inhaler, a histamine receptor blocker, and a selective serotonin reuptake inhibitor (SSRI). On pelvic exam, the cervix and uterus are midposition and normal in size and consistency, but there is diffuse pain in all areas of the pelvis, especially the right posterior cul-de-sac. The most likely cause of her pain is:
Psychogenic cause

(History of depression, suicide attempts, sexual abuse, long-standing pain, and pain unrelated to her menstrual cycle.)
A 25-year-old womna, G1, P0, is in the emergency room complaining of lower pelvic pain and spotting for the past week. Her last normal menstrual period was 7 weeks ago. You have obtained a serum beta-hCG, which was 4000 IU/L, and a transvaginal ultrasound was performed, which revealed no gestational sac in the endometrial cavity, no adnexal masses, and no free fluid in the cul-de-sac. The next best step in the management of this patient is:
Dilation and curretage
A 28-year-old woman, gravida 2, para 1, ectopic 1, presents to your clinic for an annual exam. She and her partner would like to try to have another child. Her menstrual cycles are regular, occurring every 28 days. You tell her that it is very important for her to give you a call or to come back to the clinic if she misses her period. The reason for this advice is:
Her risk of a recurrent ectopic is approximately 30%
A 23-year-old woman, gravida 3, para 1, ectopic 1, presents to your office because she missed her last period and has felt a sharp, intermittent pain in her left lower abdomen. She has no past medical history other than a left-sided ectopic pregnancy a few years ago successfully treated with methotrexate, several years after vaginal delivery of her only son. Her serum beta-hCG level is 10,500. On physical exam, her BP 110/74, P 90, T 97.8. She is obese and lacks peritoneal signs, and no masses are appreciated. A transvaginal ultrasound performed in your office reveals no gestational sac in the uterus and a 4.3-cm mass in the left adnexa separate from the ovary. What is the next best step in management of this patient?
Laparoscopic salpingectomy
A 36-year-old nulligravid woman is seen for her annual gynecologic care. She has a past medical history significant for pulmonary fibrosis. Within the past 3 years, all of the following are remarkable: bacterial vaginosis, Candida, chronic endometriosis, pyelonephritis, history of IUD that was removed 5 years ago, and history of infertility for which she was treated with fertility drugs and in vitro fertilization. She is a nonsmoker but does admit to drinking two to three alcoholic beverages every day. She has a family history significant for colon cancer in her maternal aunt. Which of the following places her at greatest risk for an ectopic pregnancy?
Infertility
A 24-year-old woman, gravida 3, para 1, spontaneous abortions 1, presents to the emergency room reporting irregular vaginal bleeding. She is found to be pregnant and her serum hCG is 3500 mIU/mL. She has a past medical history significant for diabetes mellitus and mild asthma. Her BP 103/68, P 88, and T 98.8F. Transvaginal ultrasound reveals a uterus with no gestational sac present and a 2-cm right adnexal mass. The least invasive treatment of choice is:
Methotrexate
A 25-year-old woman, gravida 2, para 2, has been trying to get pregnant for the last 2 years. She has no medical problems. She had surgery for a ruptured appendix 5 years ago. Her periods are regular and last 3 to 4 days. She denies smoking, drinking alcohol, or using drugs. Her husband is 28 years old, is healthy, and has a normal sperm count.
Tubal factor
A 29-year-old woman, gravida 5, para 1, spontaneous abortions 4, presents to you because she has not been able to carry a pregnancy successfully since the birth of her son 8 years ago. Although she becomes pregnant easily, she miscarries the pregnancy at 10 to 14 weeks. Her bimanual exam reveals an irregularly enlarged uterus (14-week size). Her husband is 34 years old and is healthy. What is the most likely cause of infertility?
Uterine factor
A 30-year-old nulligravid woman presents because she and her husband have been trying to get pregnant for the past 2 years. She has no prior medical history. She has regular, 30-day menstrual cycles and denies dysmenorrhea. Her pelvic exam is normal. Laboratory testing on cycle day 3 is normal. Ovulation is confirmed by a midluteal-phase progesterone level. You perform a hysterosalpingogram that shows a normal uterine cavity and patent bilateral fallopian tubes. Her husband is 31 years old and has a normal semen analysis. What is the most likely cause of infertility?
Unexplained
A 39-year-old woman, gravida 1, para 0 (spontaneous abortion 2 years ago), presents with 2 years of secondary infertility. She has no other medical history and has regular 30-day menstrual cycles. On her pelvic ultrasound, you noted an antral follicle count of four from the two ovaries. The hysterosalpingogram that you performed showed a normal uterine cavity and bilateral tubal patency. Her husband's semen analysis is normal. What is the most likely cause of infertility?
Oocyte quality

(low antral follicle count)
A 27-year-old woman, gravida 2, para 2, presents to you because she has not been able to get pregnant after reversal of her husband's vasectomy. She has no medical problems. What is the most likely cause of infertility?
Male factor
A 22-year-old nulligravid woman and her husband have been trying to get pregnant for the last 18 months. She has no known medical problems and has never had any surgery. She says her periods are irregular. She gets about four to five periods per year. She is 5 feet 2 inches tall and weighs 210 lb. On review of systems, she reports hair growth on her abdomen and chin. What is the most likely cause of infertility?
Ovulation

(Polycystic ovarian syndrome)
Among 100 healthy, fertile couples, approximately how many will become pregnant within 1 month if they have regular interourse?
20
A 26-year-old nulligravid and her 26-year-old husband are seeing you because they have not been able to get pregnant for the last 3 years. The woman has regular periods every 30 days that last 4 days. Both of them have no medical problems or past surgical history. Both deny smoking, caffeine use, herbal remedy use, alcohol abuse, or drug use. The husband's sperm analysis reveals a volume of 2.5 mL, total count less than 0.1 x 10^6 sperm/mL, 10% forward progression, and 30% normal morphology. The next best step in management of this couple is:
Karyotype, FSH, testosterone, Y microdeletion testing
A patient with a history of three miscarriages presents to your office. The only workup she has had done so far was a lab evaluation that showed: lupus anticoagulant negative, anticardiolipin IgA high positive, IgG low positive, and IgM normal. What would you offer the patient next?
None of the above
A couple with recurrent pregnancy loss (RPL) gets karyotype analysis and the male partner is found to have a robertsonian translocation involving chomosomes 14 and 21. The female partner is normal. The next most appropriate step in the treatment of this couple is
Send the couple for a consult with a genetic counselor
A patient with a history of three miscarriages presents to your office. The only workup she has had done so far was a lab evaluation that showed the following results: lupus anticoagulant screen negative, anticardiolipin IgG high positive, and IgM normal. What would you offer the patient next?
B & C. Repeat antiphosphlipid screen in 6 to 8 weeks & Order a hysterosalpingogram
A 15-year-old female comlains of severe dysmenorrhea that has become progressively worse since the onset of menses. Menarche occurred at age 13. The pain is located predominantly on the right side, lasts for the duration of the menstrual flow, and at it's worst is associated with nausea and vomiting. She has had to miss school with every menstrual period for the past year. She has tried NSAIDs, which initially helped but no longer relieve the pain significantly. The next step in management is:
Obtain a pelvic ultrasound
An 8-year-old girl is brought to you by her mother because of occassionally bloody vaginal discharge. Her mother suspects sexual abuse becase she doesn't "know of any other reason why a little girl should be bleeing from her vagina." She has no other medical history except for a throat infection a few weeks ago, which was treated with penicillin. On physical exam, she has enlargement of both breasts and enlarges areolae. There is no axillary hair growth. No pubic hair is apparent. The external gentalia have an age-appropriate clitoris and normal labia minora. There are no bruises, hrmatomas, or lacerations. You take a culture of the vaginal discharge, which is pink to red colored and not foul smelling. You are not able to perform a more thorough exam. The most likely cause of her vaginal bleeding is
Bacterial infection
A 6-year-old girl is brought to you because she had four urinary tract infections within the last 3 months. While the mother is holding her, you examine her genitalia. There is lack of pubic hair. The labia minora are in apposition but are easily separable with gentle traction. You note a 1-cm sized clitoris. There is a 0.3-cm cystic structure in the inferior aspect of the urethra, which is nontender to cotton swab palpation; however, it has left a red hue in your cotton swab. You order a urinalysis and a urine culture and sensitivity. The safest and next best step in management is
Sitz bath

(Prolapsed urethra- small, hemorrhagic, friable (blood on cotton swab), painless mass surrounding the urethra.)
A 24-year-old woman, gravida 1, para 1, just delivered a live female infant by natural birth. The infant weighed 3990 g and had APGARs of 8 and 9 at 1 and 5 minutes, respectively. Upon inspection of the neonate, the pediatricians are unable to assign a gender because there is clitoral hypertrophy and the labia majora are partially fused. You do not palpate any masses within them. The most important next step in management of this condition is
Serum sodium level

(Congenital adrenal hyperplasia--21-hydroxylase deficiency-- is the MCC of virilization. Salt-wasting type of CAH can be life threatening.)
You are a world-renowned reproductive endocrinologist and are asked to make a diagnosis for a patient who has ambiguous genitalia. Here are the data:
Karyotype XY
Spermatogenesis Absent
Mullerian structures Absent
Wolffian structures Present
External genitalia Male hypospadias
Breast Gynecomastia
Reifenstein syndrome

(Incomplete androgen insensitivity syndrome)
A 50-year-old 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 well at night. She is otherwise healthy and has no medical risk factors. She asks you if she is at risk for becoming pregnant with unprotected intercourse and wants your advice regarding managing her symptoms. You should:
Discuss using a low-dose combination hormonal contraceptive with her
A healthy 35-year-old woman, G2P2, presents with a history of regular menses since age 14, until her last period 1 year ago. Her hCG is negative, serum estradiol less than 20 pg/mL, FSH and LH greater than 100 mIU/mL, and prolactin less than 20 ng/mL. She has hot flashes and dyspareunia that disrupts her life. Which of the following is NOT true?
This is a typical menopausal woman

(Premature ovarian failure: menopause prior to age 40. Increased fracture risk.)
Current studies regarding the risks and benefits of HT/ET put perimenopausal and menopausal women in a treatment dilemma. Which of the following is true?
HT/ET should be given in the lowest doses for the shortest duration of time needed to achieve the desired effect
A frail 70-year-old woman with her FMP at age 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 hip T-score = -2.7. Your concerns for management include all but which of the following:
Concern that the patient's positive smoking history will exclude her from therapy to prevent future fractures
A 55-year old woman with her FMP at age 50 presents with a history of 3 days of light vaginal bleeding. You should:
Take a history, perform a physical exam, perform endometrial tissue sampling, and order a pelvic ultrasound or perform hysteroscopy
A 24-year-old woman, gravida 3, para 3, who just delivered a healthy boy and is breastfeeding him. She is a successful model and cannot tolerate excessive weight gain. She had never been able to remember to take a pill daily. Which is the best method of contraception for her?
Progesterone IUD
A 29-year-old woman who has factor V Lediden deficiency and a bicornuate uterus. She is a librarian who exercises 6 days a week in order to maintain her physique. She has had several tummultuous relationships this year. She tries to use condoms in addition to this cotraceptive method to prevent STDs. Which is the best method of contraception for her?
Progestin-only pill (minipill)
A 28-year-old nulliparous physician who has a history of major depression. She is on call in the hospital every 4 days and sometimes forgets to take her antidepressant medication. She has been in a new relationship for the past 2 months. She always uses condoms in addition to this contraceptive method to prevent STDS. Which is the best method of contraception for her?
Vaginal contraceptive ring
A 26-year-old woman, gravida 4, para 4, is happily married. She has regular periods that last 9 to 10 days, are extremely heavy, and are associated with severe cramping. She is fairly sure she has completed childbearing. Which is the best method of contraception for her?
Progesterone IUD
Your 24-year-old multiparous patient is interested in long-term contraception, but is concerned that the copper IUD acts as an abortifacient. The best guidance you could giver her is:
The main way in which the copper IUD prevents pregnancy is by acting as a spermicide
A 25-year-old woman, gravida 1, para 0, therapeutic abortions (TAB) 1, presents to the emergency department and is being evaluated for date rape, which occurred 12 hours ago. She says that the rapist forced himself onto her and had time to ejaculate inside her. She has no past medical history. In addition to prophylactic treatment for STDs, complete rape evaluation, and counseling, the most effectivce and widely available management to prevent pregnancy is:
Plan B 150 mg now
Papular rash, arthitis, and perihepatic "violin-string" adhesions. What is the causative agent?
Gram-negative diplococcus
Vulvar ulcer, marked inguinal lymphadenopathy, diagnosis by complement fixation. What is the causative agent?
Obligatory intracellular bacteria (L subtypes)
Congenital infection consisting of nonimmune hydrops, skin rash, and hepatomegaly. What is the causative agent?
Spirochete
Presence of lesion associated with prodromal symptoms. What is the causative agent?
ds-DNA virus (subtypes 1 and 2)
Vaccine currently available. What is the causative agent?
ds-DNA virus (subtypes 6/11 and 16, 18, 35, etc.)
A 22-year-old nulligravid woman presents to you 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 having intercourse with a new boyfriend. She has no known drug allergies. Today her urinalysis shows the following: 2 squamous cells, 0 nitrites, 18 WBC/hpf, 0 bacteria. Her urine hCG is negative. The next best step in management is:
Azithromycin

(Chlamydia - nongonoccal urethritis)
A 26-year-old woman, gravida 1, para 0, at 14 weeks of gestation, presents to you because of increased vaginal discharge. You perform a wet mount and test for gonorrhea and chlamydia by NAAT. The results of NAAT are positive for chlamydia. The next step in management is (note: TOC = test of cure and RS = rescreen)
Azythromycin (patient and partner) + TOC 5 weeks + RS 4 months

(Azythromycin is safe in pregnancy.)
A 20-year-old presents to you with a 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:
Gumma
A 17-year-old adolescent presents to your office reporting intense itching "down there." You perform a wet mount and KOH prep but are unable to find anything remarkable. Examination of her pubic hair in the area of the mons 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:
Permethrin 5% for 10 hours + wash bed sheets

(Scabies treatment requires more potent agents, longer duration of treatment, and neck-down treatment -- in contrast to lice. Additionally, all bedding and clothing must be washed and decontaminated.)
A 19-year-old woman, whose LMP was 32 days ago and who is sexually active, presents to the emergency department reporting a 5-day history of lower abdominal pain. Her vitals are: T 101F, BP 110/75, P 80, R 16. Speculum exam revelas purulent exudate at the cervical os, adn there is cervical motion tenderness. Bimanual exam is unremarkable for masses but produces severe discomfort. Her quantitative serum hCG = 150 mIU/mL. Urinalysis is normal. Her WBC count is 14,000. An office ultrasound shows a normal-sized, normal-striped uterus and no adnexal masses. The next best step in management of this patient is:
Clindamycin and gentamicin intravenously

(PID during pregnancy.)
The most important reason that PID must be recognized and treated promptly is prevention of:
Tubo-ovarian abscess
A 17-year-old woman has symptoms 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:
Appendicitis
A 22-year-old woman, gravida 1, para 0, total abortions 1, presents to the emergency department reporting a 6-day history of lower abdominal pain and purulent vaginal discharge. She denies past medical history or surgery. Her vitals are: T 102F, BP 118/78, P 96, R 14. Her abdomen is without scars, bowel sounds are present, and there is tenderness in the lower pelvic region of the abdomen. However, there is no rebound tenderness or 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 negativce, and WBC count = 15,000. The next best step in management is:
Pelvic ultrasound
A 22-year-old woman, gravida 1, para 0, total abortions 1, presents to the emergency department reporting a 6-day history of lower abdominal pain and purulent vaginal discharge. Bimanual exam reveals severe cervical motion tenderness and uterine tenderness. There is also a fullness in the left adnexa. The most important reason to admit this patient to the hospital is:
Pelvic examination
A married, 26-year-old woman, gravida 4, para 3, at 30 weeks' gestation, presents to you for routine prenatal care. Her medical history is remarkable for active hepatitis B and moderate asthma. She had an appendectomy 4 years ago. She has no known drug allergies. All of her prenatal labs are in order. Upon measuring her fudus, you notice several bruises in the shape of a long cylindrical object on her shins and thighs. What is the best opening question to address relationship violence?
"Are you afraid of your husband?"
A 27-year-old woman, gravida 3, para 2, spontaneous abortions 1, has been beaten many times by her husband. She wants help, but she has not told anyone about what has been happening. The most likely reason that she has not told the physician is:
She is afraid of retaliation by the partner, especially on the children
A woman discloses to her physician that her husband beats her when he is drunk and that she is afraid of him. The physician's main role is to:
Focus on patient safety issues, such as exit plans and copies of important documents
Intimate partner violence significantly increases in incidence:
Shortly after the birth of an infant
A 36-year-old woman gravida 4, para 4, presents to your clinic because she has had bilateral white-colored nipple discharge for the last 3 months. She breastfed her last baby, but that ended almost 2 years ago. She has no past medical history other than depression, for which she takes a tricyclic antidepressant. She is marries and uses birth control pills for contraception. She has no known drug allergies. Examination of the breasts reveals no discrete masses. When the nipple discharge is placed on a slide and viewed under a light microscope, fat globules are seen that are reminiscent of milk. Which of the following is the next best step in management?
Obtain a prolactin level
A 30-year-old woman, gravida 2, para 2, presents to your office reporting a mass in her right breast that she just noticed on breast self-examination. She has no medical problems. There is no history of breast or ovarian cancer in her family. Her examination is notable for a 2-cm mass in her right breast that is smooth, mobile, and nontender. Your next step is:
Obtain an ultrasound of the mass

(If the lesion is cystic, then aspirate. If it is solid, then get a mammogram.)
A 60-year-old woman, gravida 3, para 2, spontaneous abortions 1, presents to your clinic reporting brownish red-colored discharge from her left nipple. Her past medical history and medications, respectively, are diabetes, oral hypoglycemic; hypertension, ACE inhibitor; and major depression, fluoxetine. She is also taking conjugated estrogen with medroxyprogesterone acetate daily. She is allergic to penicillin. She says her mother was diagnosed with ovarian cancer at age 71. What is the next best step in management?
Ultrasound

(?The first step is obtaining a mammogram. An ultrasound could be considered if a mass is seen on mammogram.)
A 28-year-old woman, gravida 2, para 2, who delivered a healthy female infant 10 days ago, comes to labor and delivery because of a tender breast mass on the right. She is breastfeeding exclusively. On examination of her breasts 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?
Heat compresses
Embryologic homolog in the male is the floor of the penile urethra. What is the female anatomic site?
Labia minora
Embryologic homolog in the male is the Cowper glands. What is the female anatomic site?
Bartholin gland
Contains sebaceous glands but not hair follicles or sweat glands; is a paired structure. What is the female anatomic site?
Labia minora
Source of vaginal lubrication during intercourse. What is the female anatomic site?
Cervical
Azygous artery of the vagina. What is the female anatomic site?
Cervical
A 23-year-old woman, gravida 2, para 1, at 10 weeks' gestation, presents to your office and reports increasing yellow vaginal discharge that has an odor. A vaginal smear reveals clue cells. She denies pruritis. She does not have any significant medical history or allergies to medication. The next step in management of this patient is:
Vaginal metronidazole
A 25-year-old woman, gravida 1, para 1, 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 of this patient?
Screen for HIV
A 19-year-old woman complains of increasing discharge and odor. Her pH is 5.5, and wet mount reveals lack of leukocytes and protozoa. What is the diagnosis?
Bacterial vaginosis
A 24-year-old woman who is 2 months pospartum and is breastfeeding reports itching and dyspareunia. Speculum examination reveals pale, dry vaginal walls. What is the diagnosis?
Atrophic vaginitis

(?Atrophic vaginitis is unlikely in a young woman who is not estrogen deprived.)
A wet mount shows a predominance of cells with large nuclei (parabasal cells). What is the diagnosis?
Atrophic vaginitis
A 60-year-old woman, gravida 5, para 4, spontaneous abortions 1, has been treated with vaginal estrogen therapy, various pelvic muscle rehabilitation therapies, and pessaries for symptoms of pelvic prolapse without incontinence for the past 2 years. She desires definitive therapy. She has no past medical history other than hypertension, for which she takes hydrochlothiazide. All of her children were delivered vaginally. On pelvic exam, 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 stress 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 best step in management of this patient is:
Vaginal hysterectomy and anterior repair

(Hysterectomy cures uterine prolapse, anterior repair cures cystocele. Since anterior repair is performed vaginally, the hysterectomy should also be done vaginally.)
A 32-year-old woman, gravida 3, para 3, just delivered a viable female infant weighing 4000 g via cesarean section for nonreassuring fetal heart rate pattern. She received intrathecal (spinal) anesthetic and narcotic for pain relief during the procedure. Her Foley catheter is left in place for several hours after the cesarean section. This will prevent:
Overflow incontinence
A 56-year-old woman, gravida 2, para 2, who reports leaking urine when she coughs and exercises, is diagnosed with genuine stress urinary incontinence. A regimen of Kegel exercises does not improve her symptoms, and she denies more definitive treatment. Her doctor recommends laparoscopic retropubic urethropexy. When discussing the risks and benefits of the laparoscopic Burch procedure, the doctor should mention:
Risk of urinary retention
A 67-year-old woman, gravida 3, para 3, presents to your office reporting incontinence. She tells you that she voids almost 40 times during the day and has several episodes of nocturia. She says she feels like voiding two to three times an hour and that when she makes it to the bathroom, only small amounts of urine are voided. Her past medical history is remarkable for mild asthma, for which she takes albuterol. Her previous gynecologist also placed her on estrogen patch, estrogen vaginal cream, and intravaginal progesterone tablets. She had a cholecystectomy 20 years ago and she is allergic to penicillin. Her BP 130/80, P 80, Height 5'4", Weight 230 lb. On physical exam you notice pink, moist vaginal epithelium with mild cystocele and well-supported proximal urethra. The next best step in management of this patient is:
Urinalysis

(Rule out urinary tract infection.)
A 55-year-old Caucasian woman, gravida 3, para 3, who delivered all of her children by scheduled cesarean sections (prior to initiation of labor), 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 has no chronic medical prolems but is on antibiotic therapy 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:
Genetic
Advanced cervical cancer can affect this structure by extension and pressure effects.
Ureter
Advanced ovarian cancer often affects this structure by spread and encroachment
Intestine
HPV is associated with the development of cervical, vaginal, vulvar, and anal cancers. Which of the following statements is true?
The quadrivalent vaccine that is currently approved for prevention of HPV infection is over 95% effective in preventing HPV 16- and 18-related cervical cancers
A 40-year-old woman, gravida 1, para 1, presents to you because she wants to derease her risk of ovarian cancer via a prophylactic oophorectomy. She has no chronic medical problems except obesity. Her gynecologic history is remarkable for first sexual intercourse at age 15 years, four sexual partners in her entire life, and breastfeeding of her only child. Her Pap smear has shown exposure to HPV. She had infertility and conceived her only child with in vitro fertilization, and subsequently was taking birth control pills. She smokes one pack per week (for the last 10 years) and has an occasional drink with her husband. Her family history is remarkable for breast cancer in her mother and maternal grandmother and ovarian cancer in her maternal aunt. The most significant risk factor for developing ovarian cancer is her:
Family history
A 23-year-old woman, gravida 1, para 0, spontaneous abortions 1, has undergone colposcopy for evaluation of high-grade lesion found on Pap smear. The squamocolumnar junction was visible in its entirety, and the endocervical curettage was normal. A directed biopsy of the cervix revealed a 1-mm focus of invasion. The next best step in management is:
Cold knife conization of cervix (CKC)
Most common histology for cervical cancer
Squamous
Subtype of endometrial cancer with very poor prognosis; is also type of borderline ovarian tumor
Papillary serous
Most common malignant germ cell tumor
Dysgerminoma
Uncommon, aggressive vulvar cancer that is known as the most common cancer to metastasize to the placenta
Melanoma
Most common endometrial cancer
Endometroid
It is important for a physician to _____ when counseling a couple who wishes artificial insemination
Explain that there is no guarantee of pregnancy if protocol is followed
An obstetrician is called at home by a woman who is in labor. Although she has never been to see the obstetrician for a prenatal visit, she would like him to deliver her infant. The obstetrician refuses to attend to her because he is in the middle of dinner. She subsequently delivers a healthy infant at home. If this woman sues the physician for negligence, which of the following would be his best defense?
The physician never accepted the woman as his patient
A gynecologist has a longstanding relationship with a patient. The woman becomes pregnant but does not inform her gynecologist of her pregnancy and is not scheduled to see him until the next annual visit. One Saturday she calls to report nausea and vomiting but is unable to reach her physician, who is on vacation and has left no other physician to take care of his patients. Three months later the patient goes into preterm labor and delivers a premature infant. The infant ultimately dies 1 month later. In a lawsuit, which of the following statements is the physician's best defense?
The premature delivery and fetal death was unrelated to the physician's time on vacation
A 34-year-old woman, gravida 1, para 1, delivers a boy with Tay-Sachs disease. Eight year later, she and her husband obtain the services of a lawyer and sue the physician, alleging that he was remiss in genetic counseling, and because of this, a child with an irreversible neurologic disease had to be brought into the world. The best term to describe this lawsuit is:
Wrongful birth

(Wrongful birth action is brought by the parents of a child with a congenital defect, alleging that a physician was remiss in genetic counseling, and as a result a defective child was allowed to be born.)