Módulo 1 Ginecología/Obstetricia Flashcards
A 24-year-old woman presents to the emergency department complaining of right lower quadrant pain and vaginal spotting. Her last menstrual period was 5 weeks ago. Her temperature is 37.0 C (98.6 F), blood pressure is 112/70 mm Hg, pulse is 74/min, and respirations are 14/min. The abdomen is soft and nontender. Pelvic examination reveals scant blood in the vagina, a closed cervical os, no pelvic masses, and right pelvic tenderness. Her leukocyte count is 8000/mm3 , hematocrit is 38%, and a platelet count is 250,000/mm3 . Which of the following is the most appropriate step next in diagnosis?
(A) Serum hCG
(B) Serum TSH
(C) Abdominal x-ray
(D) Abdominal/pelvic CT
(E) Laparoscopy
Respuesta: A
The correct answer is A. A woman of childbearing age who presents with pain or vaginal bleeding must have a pregnancy test (urine or serum hCG) checked as one of the initial steps in her evaluation. Ectopic pregnancy is a potentially fatal condition in which a pregnancy develops outside of the uterus, most commonly in the Fallopian tube. The three most common presenting complaints for women with ectopic pregnancy are amenorrhea, abdominal pain, and vaginal bleeding. A woman may have an ectopic pregnancy and appear in no apparent distress with stable vital signs and a benign examination. Early diagnosis, however, is essential in ectopic pregnancy to avoid the significant morbidity and mortality that can result from an ectopic pregnancy that enlarges or ruptures.
Serum TSH (choice B) is an appropriate test to send as part of an outpatient evaluation of a woman having menstrual irregularities, because hypo- or hyperthyroidism can cause irregular bleeding. In the case of a young woman with abdominal pain and irregular bleeding, however, it is essential to first determine whether she is pregnant.
Abdominal x-ray (choice C) is a useful modality for identifying some types of kidney stones and gallstones, intestinal obstruction or perforation, and some abdominal masses. In this patient, however, the physician would want to know the result of the pregnancy test (hCG) prior to ordering a diagnostic study. If the hCG is positive in this woman with bleeding and abdominal pain, the appropriate diagnostic study would be pelvic ultrasound and not abdominal x- ray.
Abdominal/pelvic CT (choice D) is an effective study for identifying masses in the abdomen and pelvis. It tends to be used in cases in which the differential diagnosis includes appendicitis, abscess, or tumor. For this patient, however, the physician must determine whether she is pregnant prior to scheduling a diagnostic study.
Laparoscopy (choice E) would not be an appropriate next step in the diagnosis, as it is too invasive a procedure to perform without first checking a serum or urine hCG, and using a diagnostic study to attempt to identify the cause of this woman’s pain.
A 35-year-old African American woman presents to a physician complaining of irregular menstrual periods. She had her first menses at age 15 and states that her periods come irregularly every 2 to 6 months. She has been in a monogamous relationship with her husband for 15 years; for 10 years they have been trying unsuccessfully to conceive. She gets yearly Pap smears, which have been normal. Her height is 5 feet 2 inches (157.5 cm), and her weight is 200 pounds (90.9 kg). Her temperature is 37.0 C (98.6 F), blood pressure is 118/78 mm Hg, pulse is 80/min, and respirations are 14/min. She has acne, as well as excess hair, on her face and between her breasts. Her abdomen is obese. Examination is otherwise within normal limits. This patient is at greatest risk for developing which of the following diseases?
(A) Cervical cancer
(B) Endometrial cancer
(C) Lung cancer
(D) Osteoporosis
(E) Ovarian cancer
Respuesta: B
The correct answer is B. This patient has the constellation of findings on history and physical that are most consistent with polycystic ovarian syndrome (PCOS). Patients with PCOS typically have infertility, oligomenorrhea, hirsutism, and obesity. These women characteristically have elevated serum androgen levels, high LH to FSH ratios, and bilaterally enlarged ovaries, often with multiple cysts (which appear as “strings of pearls” on ultrasound). The oligomenorrhea that characterizes this syndrome places these women at increased risk for developing endometrial cancer. In women who ovulate each month, the second half of the menstrual cycle is characterized by production of progesterone from the ovary. This progesterone has a protective effect on the endometrium, preventing the development of hyperplasia and carcinoma. Women with PCOS, however, do not ovulate regularly and therefore do not make this “protective” progesterone each cycle. The prolonged exposure to unopposed estrogen, that is, estrogen that is not opposed by progesterone, places these women at increased risk of developing endometrial cancer.
This patient would not be considered at increased risk for developing cervical cancer (choice A). The risk factors for cervical cancer are multiple sexual partners, early age at first intercourse, history of sexually transmitted diseases, HIV, genital warts, cigarette smoking, and a history of cervical dysplasia. This patient is in a monogamous relationship and has had normal pap smears for many years.
There is no known association between PCOS and lung cancer (choice C). Women with PCOS are at increased risk of developing type 2 diabetes and dyslipidemia, however.
Osteoporosis (choice D) is a major health risk for many women. However, this patient has characteristics that make osteoporosis less of a risk for her. Osteoporosis is less common among black women than among whites or Asians. It is also less common among obese women than among thin or small framed women. Finally, osteoporosis is not considered to be a characteristic of PCOS.
Ovarian cancer (choice E) is decreased in oligoovulatory woman such as PCOS patients. Endometrial cancer is the cancer that women with PCOS are at the greatest risk of developing.
A 32-year-old Hispanic woman presents to the emergency department complaining of heavy vaginal bleeding. Her temperature is 37.0 C (98.6 F), blood pressure is 80/50 mm Hg, pulse is 110/min, and respirations are 18/min. Her abdomen is soft, nontender and nondistended. Her pelvic examination reveals approximately 200 mL of clotted blood in the vagina, an open cervical os with tissue protruding from it, and a 10-week-sized, nontender uterus. Leukocyte count is 9000/mm3 , hematocrit is 22%, and platelet count is 275,000/mm3 . Quantitative hCG is 100,000 mIU/L (normal: 5- 200,000 mIU/L). Pelvic ultrasound shows echogenic material within the uterine cavity consistent with blood or tissue, no adnexal masses, and no free fluid. No viable pregnancy is seen. Which of the following is the most appropriate next step in management?
(A) Discharge to home
(B) Culdocentesis
(C) Dilation and evacuation
(D) Laparoscopy
(E) Laparotomy
Respuesta: C
The correct answer is C. This patient has an incomplete abortion at roughly 10 weeks. We know that this is the diagnosis from a number of clues. Her os is open and she has tissue protruding from it. She has an hCG value that is consistent with a 10-week gestation (100,000 mIU/L), and her uterus is 10-week sized on examination. In her case, this abortion is causing her to lose a significant amount of blood, as evidenced by her tachycardia, low blood pressure, the large amount of clot in the vagina, and the low hematocrit. The most appropriate management for an incomplete abortion at 10 weeks with bleeding causing hemodynamic compromise is to evacuate the contents of the uterus with a dilation and evacuation. This will help to stop the bleeding by allowing the uterus to contract fully.
Discharge to home (choice A) would not be appropriate in this case because the patient has active bleeding, is hemodynamically unstable, and has a low hematocrit (22%). Delaying treatment with observation in this case might lead to a further drop in the hematocrit, further hemodynamic instability, and the eventual need for a blood transfusion with its associated risks and complications.
Culdocentesis (choice B) is a procedure used in the diagnosis of ectopic pregnancy, in which a needle is placed into the posterior cul- de-sac to determine whether there is nonclotting blood there. Ultrasound has almost completely replaced culdocentesis in the diagnosis of ectopic pregnancy.
Laparoscopy (choice D) would not be appropriate in this case. It is true that in a pregnant woman with unstable vital signs and evidence of blood loss, the physician must think about ectopic pregnancy first. In this case, however, the diagnosis of incomplete abortion is certain enough that the risks of laparoscopy would outweigh the benefits. Several things make the diagnosis of ectopic pregnancy very unlikely here. First, the hCG is 100,000 mIU/L; most ectopic pregnancies do not reach this level. Second, the uterus is 10-week- size; most ectopic pregnancies do not lead to uterine growth that is consistent with the dates of the pregnancy. Third, there is no evidence of ectopic pregnancy on the ultrasound. Ultrasonic evidence of ectopic pregnancy includes an adnexal mass, free fluid in the pelvis, and no intrauterine gestational sac.
Laparotomy (choice E) would not be appropriate in this case for the same reasons mentioned with regard to laparoscopy. When the bleeding is coming from the uterus itself from an incomplete abortion, entering the peritoneal cavity (for laparoscopy or laparotomy) will not provide a remedy for the hemorrhage.
A 25-year-old Caucasian woman, gravida 1, para 0, at 26 weeks’ gestational age presents to her physician’s office complaining of spotting from the vagina. She has no contractions and reports normal fetal movement. She denies any history of a bleeding disorder. Her temperature is 37.3 C (99.1 F), blood pressure is 100/60 mm Hg, pulse is 75/min, and respirations are 14/min. Her abdomen is gravid and benign, with a fundal height of 26 cm. A placenta previa is ruled out by ultrasound examination. Pelvic examination reveals some scant blood in the vagina, a closed os, and no uterine tenderness. Leukocyte count is 12,000/mm3, hematocrit is 33%, and platelet count is 140,000/mm3 . Her blood type is A, Rh negative. Which of the following is the most appropriate pharmacotherapy?
(A) Antibiotics
(B) Blood transfusion
(C) Magnesium sulfate
(D) Platelet transfusion
(E) RhoGAM™
Respuesta: E
The correct answer is E. A woman who is pregnant and bleeding should have her blood type checked. If her blood type is Rh negative, she should receive RhoGAM unless the father of the child is known with certainly to be Rh-negative. RhoGAM is anti-D immune globulin, which will bind to the D subtype of the Rh antigen. It is given to prevent Rh isoimmunization. The Rh, or Rhesus, antigen is found on the red blood cells of most people. However, a certain percentage of women will not have the Rh antigen on their red blood cells. Rh isoimmunization occurs when an Rh-negative mother gets sensitized by being exposed to the Rh antigen of her fetus’ red blood cells. This exposure may occur whenever the woman has an episode of bleeding, (with trauma, an amniocentesis, or delivery). She then may make antibodies against the Rh antigen. These antibodies typically do not affect the initial pregnancy of the exposure. However, in a subsequent pregnancy, if that fetus also is Rh positive and the Rh-negative mother has been previously sensitized by an Rh-positive fetus, the mother may mount an immune response against the red blood cells of her fetus. The antibodies that she makes may cross the placenta and destroy the fetal red blood cells. This process can lead to significant fetal morbidity and mortality. RhoGAM should be given to any Rh- negative pregnant woman who has an episode of bleeding. If there is no bleeding during the pregnancy, then it should be given routinely at about 28 weeks and again postpartum if the neonate is Rh positive.
Antibiotics (choice A) would not be indicated here. There is a normal leukocytosis of pregnancy, with white cell counts ranging from 5000 to 12,000/mm3 . During labor and immediately postpartum, it may become even more elevated, averaging 14,000- 16,000/mm3 . This patient has no evidence of infection on the basis of her vital signs, examination, or laboratory values; therefore, antibiotics would not be indicated.
Blood transfusion (choice B) would not be indicated here. On average, healthy pregnant women will have lower hematocrits than nonpregnant women. Some refer to this as the “physiologic anemia of pregnancy.” Therefore, a hematocrit of 33% is a routine finding during normal pregnancy and would not be an indication for transfusion.
Magnesium sulfate (choice C) is a drug commonly used in obstetrics. It is used for the treatment of preterm labor and for the prevention of seizures in patients with preeclampsia. Although bleeding from the vagina can be a sign of preterm labor, this patient has a normal, closed cervical os and has had no contractions. She also has no symptoms or findings to suggest preeclampsia, which is diagnosed on the basis of hypertension, edema, and proteinuria. Therefore, magnesium sulfate would not be used in this patient.
Platelet transfusion (choice D) would not be indicated here. Many normal pregnancies are characterized by a drop in the platelet count to a low-normal or even below normal value. When it is below normal, it is termed gestational thrombocytopenia. No intervention is necessary in the case of gestational thrombocytopenia. Platelet transfusions are reserved for more severe cases of bleeding, in the presence of a bleeding disorder, or for a surgical procedure.
A 29-year-old primigravid woman is admitted to the labor and delivery ward with strong contractions every 2 minutes and cervical change from 3 to 4 cm. Over the next 5 hours she progresses to full dilation. After 3 hours of pushing, the physician cuts a mediolateral episiotomy, and the woman delivers a 3770-g (8-lb, 4-oz) boy. Which of the following is the main advantage of a mediolateral episiotomy over a median (midline) episiotomy?
(A) Easier surgical repair of the episiotomy
(B) Improved healing of the episiotomy
(C) Less blood loss
(D) Less likely to cause a fourth-degree extension
(E) Less pain
Respuesta: D
The correct answer is D. A mediolateral episiotomy is made from the introitus at a 45-degree angle from the midline. Its main advantage over the median episiotomy, which starts from the introitus and goes down the perineum in the midline, is that the mediolateral episiotomy is less likely to result in a fourth-degree extension, which is a tear of the tissues from the vaginal mucosa to and through the rectal mucosa.
Easier surgical repair of the episiotomy (choice A), improved healing of the episiotomy (choice B), less blood loss (choice C), and less pain (choice E) are all characteristics of the median episiotomy and they are all advantages that the median episiotomy has over the mediolateral episiotomy. Again, however, the main advantage of the mediolateral episiotomy is that it is less likely to result in a fourth- degree extension.
A 22-year-old woman presents with mouth sores, sore throat, vaginal discharge, fever, and myalgia. She has no other medical problems. She takes oral contraceptive pills. She is in a monogamous relationship and states that her partner occasionally uses barrier contraception. Physical examination reveals a temperature of 38.3 C (101.0 F), cervical and inguinal lymphadenopathy, exudative pharyngitis, and multiple ulcers on the oral mucosa, the labia, and cervix. The vaginal discharge is profuse, and Gram stain indicates many neutrophils. Which of the following is the most likely diagnosis?
(A) Chancroid
(B) Condyloma acuminatum
(C) Herpes simplex virus
(D) Lymphogranuloma venereum
(E) Syphilis
Respuesta: C
The correct answer is C. Primary herpes infection can cause systemic symptoms of fever and myalgia and can affect the pharynx, urethra, external genitalia, and cervix. Although no effective therapy is available, acyclovir is used to reduce morbidity of the disease and decrease the incidence of recurrences.
Chancroid (choice A) does not cause systemic symptoms and leads to a soft, non-indurated, painful ulcer. The etiologic agent is Haemophilus ducreyi, which requires growth on an enriched chocolate medium. Management consists of oral erythromycin.
Condyloma (choice B) causes characteristic large, soft, fleshy, cauliflower-like excrescences around the vulva, urethral orifice, anus, and perineum. The causative agent is the human papilloma virus (HPV). Most HPV lesions resolve spontaneously. Frequently used therapies include cryosurgery, application of caustic agents, electrodesiccation, surgical excision, and laser ablation. Topical podophyllin has also been used with some success.
Lymphogranuloma venereum (choice D) leads to fever, arthritis, pericarditis, painless papules, and erythema nodosum. This is a sexually transmitted infection caused by Chlamydia trachomatis strains. A frequent presenting symptom is painful inguinal lymphadenopathy. Azithromycin may be of utility in treatment.
Syphilis (choice E) usually causes a single ulcer and does not produce exudative pharyngitis. Clinical manifestations of syphilis include primary, secondary, and tertiary syphilis. The primary chancre usually begins as a single painless papule, which rapidly becomes eroded and usually, but not always, is indurated with a characteristic cartilaginous consistency on palpation of the edge and base of the ulcer. Penicillin G is the drug of choice for all stages of syphilis.
A 34-year-old woman, gravida 3, para 2, at 38 weeks’ gestation presents to the labor and delivery ward complaining of headache. She has no contractions. Her prenatal course was unremarkable until she noted the onset of swelling in her face, hands, and feet this week. Her obstetric history is significant for two normal spontaneous vaginal deliveries. She has no significant past medical or surgical history. Her temperature is 37.0 C (98.6 F), blood pressure is 160/92 mm Hg, pulse is 78/min, and respirations are 16/min. Examination reveals 3+ patellar reflexes bilaterally. A cervical examination reveals that her cervix is 3 cm dilated and 50% effaced and soft, and that the fetus is at 0 station and vertex. The fetal heart rate has a baseline of 140/min and is reactive. The results from a 24-hour urine collection show 5200 mg of protein (normal < 300 mg/24 hours). The patient is given magnesium sulfate intravenously for seizure prophylaxis. Which of the following is the most appropriate next step in the management of this patient?
(A) Expectant management
(B) Intramuscular glucocorticoids
(C) IV oxytocin
(D) Subcutaneous terbutaline
(E) Cesarean section
Respuesta: C
The correct answer is C. This patient has the symptoms, signs, and laboratory values consistent with severe preeclampsia. Preeclampsia is diagnosed on the basis of hypertension, edema, and proteinuria. A patient is considered to have severe preeclampsia when she has any of the following manifestations: 1) headache, visual changes, or grand-mal seizure (eclampsia); 2) blood pressure greater than 160-180 mm Hg systolic or 110 mm Hg diastolic; 3) pulmonary edema; 4) right upper quadrant pain or elevated liver function tests; 5) oliguria (< 500 mL/24 hours), elevated serum creatinine, or severe proteinuria (> 5 g/24 hours); 6) microangiopathic hemolytic anemia or thrombocytopenia; and 7) oligohydramnios or fetal intrauterine growth restriction. This patient meets the criteria of severe preeclampsia on the basis of her headache and her 24-hour urine with greater than 5 g of protein in 24 hours. The only cure for preeclampsia is delivery of the fetus. With a favorable cervix and a history of two prior normal spontaneous vaginal deliveries, this patient would be an excellent candidate for labor induction with IV oxytocin.
There is no role for expectant management (choice A) in the treatment of severe preeclampsia after 32 weeks. Some physicians choose to follow expectant management with women with severe preeclampsia prior to 32 weeks to allow for the administration of glucocorticoids and maturation of the fetus. This patient, however, is at 38 weeks’ gestation; therefore, expectant management would not be appropriate.
Glucocorticoids (choice B) given to the mother have been shown to be effective in preventing certain sequelae of prematurity in the neonate. Maternal steroids have been shown to reduce the incidence of respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC). They have also been shown to reduce perinatal mortality. This patient, however, is at 38 weeks’ gestation and therefore not having a premature delivery. Thus, administration of glucocorticoids would not be appropriate.
Subcutaneous terbutaline (choice D) is used as a uterine relaxant in cases of preterm labor or uterine tetany (prolonged contraction of the uterus). It would have no role in this patient.
Cesarean section (choice E) would not be considered the mode of choice for the delivery of a patient with severe preeclampsia with two prior vaginal deliveries and a favorable cervix. Severe preeclampsia at 38 weeks’ gestation is certainly an indication for delivery, but vaginal delivery would be preferred over cesarean section in this patient.
A 64-year-old woman undergoes left radical mastectomy for breast cancer. A 4-cm infiltrating ductal carcinoma is found on pathologic examination. Four of 20 axillary lymph nodes are positive for malignancy. Neoplastic cells are immunoreactive for estrogen and progesterone receptors. No evidence of metastatic disease is found on bone scanning with 99mTc-labeled phosphate or chest x-ray films. The patient receives appropriate radiation therapy and multidrug chemotherapy. Which of the following is the most appropriate adjunctive therapy in this setting?
(A) Danazol
(B) Ethinyl estradiol
(C) Megestrol acetate
(D) Medroxyprogesterone acetate
(E) Natural progesterone
(F) Tamoxifen
Respuesta: F
The correct answer is F. After surgery and radiation therapy, chemotherapy and other forms of adjunctive treatments are recommended for most cases of potentially curable breast cancer. Chemotherapeutic regimens vary in relation to whether patients are pre- or postmenopausal, but hormonal adjunctive treatment has proven beneficial in both groups. Tamoxifen is an anti-estrogen used for treatment of breast cancer, and tumors that express estrogen/progesterone receptors respond better to it. In addition, tamoxifen results in better survival regardless of tumor staging or grading. Therefore, receptor status is evaluated routinely in breast cancer by immunohistochemical staining with antibodies to estrogen/progesterone receptors. However, the physician must be on the alert for paradoxical tamoxifen-induced endometrial hyperplasia.
Danazol (choice A) and medroxyprogesterone acetate (choice D) are used to treat a variety of gynecologic conditions, including endometriosis and abnormal uterine bleeding, but certainly not breast cancer. Danazol has also been used for symptomatic mammary dysplasia (fibrocystic changes).
Ethinyl estradiol (choice B) is used for treatment of abnormal uterine bleeding, estrogen replacement therapy, and adjunctive hormonal treatment for prostatic carcinoma.
Megestrol acetate (choice C) has been used for treatment of prostatic hyperplasia and endometrial cancer. This compound is also used for postmenopausal women with breast cancer in whom tamoxifen is not effective. In the latter situation, megestrol acetate is thus used as a second-line hormonal agent.
Natural progesterone (choice E) may benefit women with premenstrual syndrome.
A 23-year-old gravida 3, para 2 is admitted to the hospital at 31 weeks’ gestation with painful uterine contractions. Her cervix is initially 3 cm dilated. Magnesium sulfate is started. Over the next 5 hours, she progresses to full dilation. After a 1-hour second stage, she delivers a 2013-g (4-lb, 7-oz) newborn. In the neonatal intensive care unit, the infant develops respiratory distress and pneumonia. Over the following days the infant develops septicemia. Preliminary blood cultures demonstrate gram-positive cocci in chains. Treatment with which of the following would most likely have prevented this neonatal outcome?
(A) Folic acid
(B) Gentamicin
(C) Naloxone
(D) Oxytocin
(E) Penicillin
Respuesta: E
The correct answer is E. This infant most likely has sepsis due to Group B streptococci (GBS). GBS are a part of the normal flora of many women. During pregnancy, as many as 20 to 40% of women will be colonized with GBS. Most neonates born to colonized mothers will not develop infection with GBS; however, approximately 1 to 4% will. The likelihood of infection is increased if the mother has preterm labor and delivery (< 37 weeks), prolonged rupture of the membranes (> 18 hours), or intrapartum temperature greater than 100.4 F. Two primary methods are used to determine which women should receive antibiotics during labor. The first method is based on five risk factors: 1) history of a GBS-affected neonate; 2) urine culture with GBS; 3) preterm labor (< 37 weeks); 4) membranes ruptured for more than 18 hours in labor; and 5) temperature greater than 100.4 F in labor. A woman with any one of these five risk factors should receive antibiotics. The second method is based on screening, with pregnant women being screened for GBS at 35-37 weeks with a culture of the vagina, perineum, and anus. In this patient, however, labor and delivery occurred at 31 weeks’ gestation. Treatment with penicillin may have prevented the neonate from developing GBS sepsis.
Folic acid (choice A) is a supplement that women should take preconceptionally and during pregnancy to help prevent neural tube defects. This neonate does not have a neural tube defect.
Gentamicin (choice B) is an antibiotic that is effective in the treatment of gram-negative bacteria. As this infection was caused by a gram-positive coccus, gentamicin would not be the drug of choice.
Naloxone (choice C) is an opioid antagonist. It is given to neonates who demonstrate signs of depression after the laboring mother has been treated with narcotics. This infant has no signs of narcotic depression; therefore, naloxone would not be indicated.
Oxytocin (choice D) is given to women to induce or to augment labor. It can also be given postpartum to assist in uterine contractions in the case of atony and post-partum hemorrhage. This patient is preterm and has no indication for early delivery; therefore, oxytocin would not be indicated.
A 26-year-old nulligravid patient presents to her physician seeking preconceptional advice. She plans to conceive in about 1 year. Her past medical history is significant for chickenpox as a child. She had an appendectomy 2 years ago. She takes no medications and is allergic to penicillin. Her complete physical examination, including a pelvic examination, is unremarkable. Which of the following is the most appropriate next step in diagnosis to prevent morbidity in this patient’s offspring?
(A) Blood cultures
(B) Group B Streptococcus culture
(C) Pelvic ultrasound
(D) Rubella titer
(E) Urine culture
Respuesta: D
The correct answer is D. Preconceptional counseling is an essential part of the care of any young woman who plans to become pregnant. A detailed history and physical should be performed, including past obstetric history and any family history of congenital anomalies. Laboratory tests should include a rubella titer and a varicella-zoster titer. If the patient has a negative rubella titer, she should be given the MMR (measles-mumps-rubella) vaccine. Being vaccinated against rubella will prevent her from acquiring rubella during pregnancy. Rubella infection during pregnancy can lead to congenital rubella syndrome, a potentially devastating disorder that can lead to ear, eye, brain, and heart anomalies in the fetus. The patient should be counseled to avoid becoming pregnant for 3 months after the immunization since this is a live attenuated vaccine.
Blood cultures (choice A) are performed on patients when there is concern for bacteremia (bacteria present in the blood). This patient has no evidence of infection, and routine preconceptional blood cultures are not indicated.
Group B Streptococcus (GBS) culture (choice B) is performed on pregnant women in the third trimester to determine whether they have been colonized with this bacterium. If a woman is colonized, she should be given antibiotics in labor to prevent GBS disease in the newborn. This culture is performed in the third trimester and would not be indicated preconceptionally.
Pelvic ultrasound (choice C) is an excellent diagnostic tool for imaging the pelvis. It is useful in the diagnosis of ectopic pregnancy, ovarian torsion, tubo-ovarian abscess, ovarian masses, and other pelvic processes. It would not be indicated in an asymptomatic 26- year-old with a normal pelvic examination.
Urine culture (choice E) is used to diagnose a urinary tract infection (UTI). This patient has nothing in her history or physical that suggests active UTI or susceptibility to UTI. Therefore, urine culture would not be indicated in this patient.
A 26-year-old black gravida 2, para 1, at 32 weeks’ gestation presents to the physician for a prenatal visit. Her prenatal course has been remarkable for hyperemesis gravidarum in the first trimester. She also had a urine culture in the first trimester that grew out Group B Streptococcus. She has had type 1 diabetes for the past 2 years and has had good control of her blood glucose levels during this pregnancy. Her first pregnancy resulted in a low transverse cesarean section for dystocia. Other than insulin, she takes no medicines and has no known drug allergies. After a routine prenatal visit, the physician sends her to the antepartum fetal testing unit to undergo a nonstress test (NST). Which of the following characteristics makes this patient a good candidate for antepartum fetal testing with an NST?
(A) Black race
(B) Diabetes mellitus
(C) Group B Streptococcus urine culture
(D) History of cesarean section
(E) Hyperemesis gravidarum
Respuesta: B
The correct answer is B. Women with diabetes mellitus are at increased risk for sudden intrauterine death. In the past, antepartum fetal death occurred in as many as 20 to 30% of patients with type 1 (insulin requiring) diabetes. Now, with improved maternal care and fetal surveillance, sudden intrauterine death is rare. Fetal surveillance usually begins at 28-32 weeks’ gestation and consists of twice weekly nonstress tests (NST) until the mother delivers. An NST is reactive if there are two accelerations of the fetal heart rate (an increase of 15/min for 15 seconds) in 20 minutes. If the NST is not reactive, uteroacoustic stimulation should be performed, followed by a contraction stress test or biophysical profile. Management would then be based on the outcome of those tests. Many obstetric outcomes vary according to race. However, black race (choice A) would not be an indication for antepartum fetal testing. In this patient, her diabetes mellitus makes her a candidate for such testing, not her race.
A urine culture positive for group B Streptococcus (GBS) (choice C) is an indication for antibiotic prophylaxis during labor and delivery to prevent GBS invasive disease in the newborn. A positive GBS urine culture is not an indication for antepartum fetal testing.
History of cesarean section (choice D) is an important aspect of the patient’s past obstetric history. However, in the absence of diabetes mellitus, a prior c-section is not an indication for antepartum fetal testing.
Hyperemesis gravidarum (choice E) is a condition of pregnancy characterized by persistent nausea and vomiting. It is most often limited to the first trimester and usually resolves by 16 weeks’ gestation. Although hyperemesis gravidarum can be a difficult condition for the patient, it is not an indication for antepartum fetal testing.
A 19-year-old gravida 2, para 1 woman presents at her first prenatal visit complaining of a rash, hair loss, and spots on her tongue. Her temperature is 37.0 C (98.6 F), blood pressure is 112/74 mm Hg, pulse is 68/min, and respirations are 14/min. Physical examination is significant for a maculopapular rash on her trunk and extremities, including her palms and soles. She has “moth-eaten” alopecia and white patches on her tongue. Her uterus is 10-week size, which is consistent with her dating by last menstrual period. The rest of her examination is unremarkable. RPR and MHA-TP are positive. Which of the following is the most appropriate pharmacotherapy?
(A) Clindamycin
(B) Gentamicin
(C) Nitrofurantoin
(D) Penicillin
(E) Tetracycline
Respuesta: D
The correct answer is D. This patient has syphilis, a disease caused by Treponema pallidum, a spirochete, as evidenced by the positive rapid plasma reagin (RPR) test and microhemagglutination assay for antibodies to T. pallidum (MHA-TP). Primary syphilis is characterized by a painless ulcer, called a chancre, typically found on the vagina or cervix. Untreated primary syphilis can progress to secondary syphilis, which is characterized by “moth-eaten” alopecia, a maculopapular skin rash involving the palms and soles, and white patches on the tongue. Tertiary syphilis is characterized by gumma formation, cardiac lesions, and CNS abnormalities. Syphilis in pregnancy is associated with increased rates of pre-term delivery, intrauterine growth retardation, and fetal demise. However, the most devastating complication of syphilis in pregnancy is congenital infection of the fetus, which can lead to severe effects on fetal morbidity and mortality. The key to preventing congenital infection is adequate treatment of the mother. The drug of choice for syphilis is penicillin.
Clindamycin (choice A) is effective for some grampositive and anaerobic infections. It does not treat syphilis and would not be indicated for this patient.
Gentamicin (choice B) is mostly used for gramnegative infections. It does not treat syphilis and would not be indicated.
Nitrofurantoin (choice C) is often used in pregnancy to treat urinary tract infections. However, it does not treat syphilis and therefore would not be indicated for this patient.
Tetracycline (choice E) should not be used in pregnancy, as it is known to cause discoloration of deciduous teeth and it can be deposited into fetal long bones. It is considered a second-line treatment of syphilis in the non-pregnant patient.
A 34-year-old woman with breast cancer presents to her physician complaining of increased weakness, lower back pain, and urinary incontinence. She was diagnosed with breast cancer 2 years ago and is undergoing radiation and chemotherapy. Her back pain developed 2 days ago. Physical examination shows lower extremity weakness and hyporeflexia. Which of the following is the most appropriate next step in this patient’s care?
(A) Obtain a neurologic consultation
(B) Obtain an emergency spinal MRI
(C) Administer narcotics for pain relief
(D) Administer high-dose steroids
(E) Perform a lumbar puncture
Respuesta: D
The correct answer is D. This patient probably has breast cancer metastases to the spine and is in danger of spinal cord compression, which is an emergency. It is essential to administer steroids immediately to help decrease the swelling and relieve some compression. She might ultimately need surgical intervention or radiation.
A neurologic consultation (choice A) will help localize the lesion; however, this is an emergency and must be treated immediately.
An MRI (choice B) will localize the lesion but should not delay emergent intervention.
Narcotics (choice C) would provide only symptomatic relief.
A lumbar puncture (choice E) might reveal malignant cells on cytologic evaluation but would not contribute to her immediate management.
An otherwise healthy, 65-year-old woman comes to the physician because of bloody discharge from the right nipple for 2 weeks. On examination, no retraction, erosion, or other abnormal change is present. Palpation reveals an ill-defined, 1-cm nodule located deep in the right areola. Which of the following is the most appropriate next step in diagnosis?
(A) Cytologic examination of nipple discharge
(B) Mammography alone
(C) Ultrasonography
(D) Biopsy under mammographic localization
(E) Mammography followed by fine-needle cytology
Respuesta: E
The correct answer is E. Nipple discharge in the nonlactating breast may be the presenting sign of a number of diseases, the most common of which are intraductal papilloma, carcinoma, and fibrocystic changes. Carcinoma is more likely in women older than 50. Regardless of whether this sign is present, a clinically malignant palpable mass in a postmenopausal woman should be investigated with mammography followed by fine-needle cytology (or excisional biopsy). The features suspicious for malignancy in this case include ill-defined margins of the mass and the hemorrhagic nature of the discharge.
Cytologic examination of nipple discharge (choice A) may reveal malignant cells but is associated too frequently with false negative results to be reliable.
Mammography alone (choice B) is adequate if the breast mass appears benign on clinical grounds. Biopsy or fine-needle aspiration may then be carried out depending on the mammographic findings.
Ultrasonography (choice C) is mainly used to differentiate between solid and cystic masses. However, it does not allow any inference on the malignant versus benign nature of a lesion. If a lesion is cystic, the fluid should be aspirated and examined cytologically.
Biopsy under mammographic localization (choice D), i.e., a “stereotactic” biopsy, is not necessary in this case because the lesion is palpable and can be easily sampled by fine-needle aspiration or conventional biopsy.
A 34-year-old woman, gravida 3, para 2, at 16 weeks’ gestation comes to the physician concerned that she may have been exposed to an infectious disease. Yesterday, she and her 5-year-old son spent a day at the beach with one of his classmates. This morning, the classmate was sent home from school with a fever and rash that the teacher thought were suspicious for chickenpox. The patient is unsure whether she had chickenpox as a child. Her temperature is 37 C (98.6 F), blood pressure is 100/70 mm Hg, pulse is 88/min, and respirations are 16/min. Her examination is unremarkable. An inquiry made by the physician confirms that the classmate has chickenpox. Which of the following is the most appropriate next step in management?
(A) Check an IgG varicella serology
(B) Wait to see whether a rash develops
(C) Administer IV acyclovir
(D) Administer oral acyclovir
(E) Administer varicella vaccine
Respuesta: A
The correct answer is A. The varicella-zoster virus, the virus that causes the clinical manifestations that are commonly referred to as “chickenpox,” can have severe consequences for a mother and her fetus during pregnancy. Fortunately, most pregnant women have already been exposed. And, of those pregnant women who are not sure whether they had chickenpox, the overwhelming majority will also have already been exposed and be immune to infection. The ideal time to screen for immunity to varicella is preconceptionally. If a pregnant women thinks she has been exposed, then the first step is to verify that the infected person truly has varicella. The next step is to check the mother’s IgG serology. If her serology is positive, then she has immunity and there is no risk to her or her fetus. If the serology is negative, she should be given varicella-zoster immune globulin (VZIG), which is about 75% effective in preventing an infection if given within 96 hours of exposure.
Waiting to see whether a rash develops (choice B) would not be appropriate. The incubation period for the virus is 10-14 days. VZIG is most effective if given within 96 hours of exposure. Therefore, this patient may not develop a rash for 10 or more days, and by that time it would be too late for VZIG.
Administration of IV acyclovir (choice C) would be inappropriate. First, the mother most likely has already had varicella infection and is therefore immune. Second, the mother has no evidence of being infected. Finally, even in the case of a confirmed maternal infection, IV acyclovir is used only when serious complications of varicella infection (e.g., pneumonia or encephalitis) develop.
Administration of oral acyclovir (choice D) would be inappropriate for the above listed reasons.
Administration of the varicella vaccine (choice E) would be contraindicated because it is an attenuated live-virus vaccine. These vaccines are not recommended for pregnant women.
A 26-year-old primigravid woman at 10-weeks’ gestation comes to the physician for a routine prenatal appointment. Her dating is based on a 6-week ultrasound. She has sickle-cell anemia. She has no past surgical history, takes prenatal vitamins, and has no known drug allergies. She tells the physician that she recently learned that the father of the baby has sickle-cell trait. On examination, her uterus is appropriate for a 10-week gestation, and fetal heart tones are heard. Her hematocrit is 37%. What is the most appropriate next step in the management of this patient?
(A) Genetic counseling
(B) Obstetric ultrasound
(C) Hydroxyurea
(D) IV hydration
(E) Blood transfusion
Respuesta: A
The correct answer is A. Sickle-cell anemia results from a single A-T substitution that leads to valine being substituted for glutamic acid on the beta-chain of the hemoglobin molecule. This change in the configuration of the hemoglobin molecule makes the erythrocyte sickle when it becomes deoxygenated. Patients with sickle-cell anemia have a number of maladies, including severe pain crises, pulmonary infarction, bony abnormalities, cerebrovascular accidents, and an increased likelihood of infection with gram- positive organisms. This patient has sickle-cell anemia (SS), and the father of the baby has sickle-cell trait (AS). This gives the fetus a 50% likelihood of having sickle-cell disease and a 50% likelihood of having sickle-cell trait. Amniocentesis and chorionic villus sampling can be used to determine the genotype of the fetus. This patient should at least be offered the option of having genetic counseling to better understand the inheritance of the disease and the fetus’ likelihood of having each outcome.
Obstetric ultrasound (choice B) is a very useful diagnostic modality to examine the fetus, umbilical cord, placenta, amniotic fluid, and maternal pelvic structures. This patient, however, does not have an indication for an ultrasound at this time. This patient already had a 6-week ultrasound, which is especially useful for dating the pregnancy. The best time to do a “screening” ultrasound to look for fetal anomalies is during the second trimester. This patient, at 10- weeks’ gestation with an ultrasound done 4 weeks ago, would have no indication for another ultrasound at this time.
Hydroxyurea (choice C) is a drug used to increase the production of hemoglobin F in patients with sickle-cell anemia who are not pregnant. It is considered a class D drug, and its use in pregnancy is limited.
IV hydration (choice D) is frequently used in patients with sickle- cell anemia during pain crises. This patient has no evidence of having a pain crisis; therefore, IV hydration would not be indicated during a prenatal visit.
Blood transfusion (choice E) during pregnancy for the patient with sickle-cell anemia is an area of controversy. Some argue for routine transfusion to maintain the hematocrit above 25% and the level of hemoglobin A above 40%. This patient is asymptomatic, with a hematocrit of 37% at 10 weeks’ gestation. Therefore, blood transfusion would not be indicated as the next step in management.
A 23-year-old woman, gravida 1, para 0, at 25 weeks’ gestation comes to the physician because of right upper quadrant pain, nausea and vomiting, and malaise for the past 2 days. Her temperature is 37.0 C (98.6 F), blood pressure is 104/72 mm Hg, pulse is 92/min, and respirations are 16/min. Physical examination reveals right upper quadrant tenderness to palpation. The cervix is long, closed, and posterior. There is generalized edema. Laboratory values are as follows:
- Leukocyte count 10,500/mm3
- Platelet count 62,000/mm3
- Hematocrit 26%
- Sodium 140 mEq/L
- Chloride 100 mEq/L
- Potassium 4.5 mEq/L
- Bicarbonate 26 mEq/L
A peripheral blood smear reveals hemolysis. Which of the following laboratory findings would be most likely in this patient?
(A) Decreased fibrin split products
(B) Decreased lactate dehydrogenase
(C) Elevated AST
(D) Elevated fibrinogen
(E) Elevated glucose
Respuesta: C
The correct answer is C. This patient has the findings consistent with HELLP syndrome. HELLP stands for hemolysis, elevated liver enzymes, and low platelets, and is related to preeclampsia. A patient with HELLP typically presents with complaints of abdominal pain and nausea and vomiting, as well as a history of malaise or flu-like symptoms. The patients are usually afebrile and often have normal vital signs. Although HELLP is related to preeclampsia, hypertension and proteinuria may be absent or minimal. Examination usually reveals right upper quadrant or epigastric tenderness. Laboratory values show evidence of hemolysis (e.g., abnormal peripheral blood smear, elevated lactate dehydrogenase, and increased bilirubin), elevated liver enzymes (e.g., elevated AST and ALT), and low platelets (< 100,000/mm3). The treatment is essentially the same as for severe preeclampsia.
Decreased fibrin split products (choice A) would not be consistent with HELLP syndrome. Up to 40% of patients with HELLP syndrome will develop disseminated intravascular coagulation (DIC). In DIC, fibrin split products are elevated.
Decreased lactate dehydrogenase (choice B) would also not be consistent with HELLP syndrome. As noted above, lactate dehydrogenase rises as hemolysis takes place and the liver is damaged.
Elevated fibrinogen (choice D) would also not usually be seen in HELLP syndrome. In the up to 40% of patients with HELLP who develop DIC, the fibrinogen level would be decreased.
Elevated glucose (choice E) would not usually be seen in HELLP syndrome.
A 17-year-old woman, gravida 1, para 0, at 38 weeks’ gestation comes to the labor and delivery ward because of contractions. Her dating was determined by a 7-week ultrasound. Her prenatal course was complicated by gestational diabetes. Her past surgical history is significant for shoulder surgery. She takes insulin and prenatal vitamins. She has no known drug allergies. She smokes 3 to 4 cigarettes per day. She is initially found to be 4 cm dilated and is contracting every 2 to 3 minutes. She is admitted to the labor and delivery ward and, over the next 4 hours, progresses to full dilation. After pushing for 2 hours, she delivers the fetal head but has great difficulty delivering the fetal shoulders. Eventually, the fetus is delivered by the posterior arm. In the process of delivery the newborn’s humerus is fractured. Which of the following factors contributed the most to the difficult delivery of the fetus?
(A) Cigarette smoking
(B) Gestational age
(C) Gestational diabetes
(D) Maternal age
(E) Maternal shoulder surgery
Respuesta: C
The correct answer is C. Gestational diabetes is defined as glucose intolerance that develops or is first recognized during pregnancy. To diagnose gestational diabetes, a 50-g oral glucose tolerance test (OGTT) is given between 24 and 28 weeks. Any woman with a plasma glucose value above 140 mg/dL on the 50-g OGTT is then sent for a 100-g, 3-hour OGTT, in which a 100-g glucose load is given and plasma glucose levels are checked at 1, 2, and 3 hours. Any woman with two or more abnormal values is considered to have gestational diabetes. A class A1 gestational diabetic does not have fasting hyperglycemia (glucose >105 mg/dL) and can usually be treated with diet alone. A class A2 gestational diabetic has fasting hyperglycemia and needs insulin treatment. Gestational diabetics are at increased risk for fetal macrosomia. Fetal macrosomia is a risk factor for shoulder dystocia, a condition in which the fetus’ anterior shoulder becomes impacted against the mother’s pubic symphysis. This fetus had a shoulder dystocia that was relieved only with delivery of the posterior arm. In the process, the humerus was fractured. The shoulder dystocia was likely the result of the fetal macrosomia, which was most likely caused by the mother’s gestational diabetes.
Cigarette smoking (choice A) has not been shown to be related to shoulder dystocia.
Gestational age (choice B) is related to shoulder dystocia when the patient is post-dates (>40 weeks). This patient, however, is at 38 weeks’ gestation.
There is some evidence that advanced maternal age (choice D) may be related to shoulder dystocia. This patient is 17; therefore, advanced maternal age is not a factor.
Maternal shoulder surgery (choice E) is not related to the occurrence of shoulder dystocia.
A 22-year-old woman comes to the physician seeking advice. Last night, while she was having sexual intercourse, the condom broke. She is very concerned that she may become pregnant and wants to know whether she can do anything at this point. She has no medical problems and has never had surgery. She takes ibuprofen for dysmenorrhea. She is allergic to sulfa drugs. On physical examination, she is anxious and intermittently sobbing. Her temperature is 37.0 C (98.6 F), blood pressure is 140/90 mm Hg, pulse is 98/min, and respirations are 24/min. The remainder of her physical examination is unremarkable. A urine pregnancy test is negative. Which of the following is the most appropriate pharmacotherapy?
(A) Clomiphene
(B) Gentamicin
(C) Labetalol
(D) Norgestrel/ethinyl estradiol
(E) Trimethoprim-sulfamethoxazole
Respuesta: D
The correct answer is D. Postcoital contraception is a safe and highly effective method of preventing pregnancy. It is useful to check a pregnancy test prior to giving any treatment to ensure that the patient is not already pregnant. One of the most common methods of postcoital contraception is to administer norgestrel/ethinyl estradiol (Ovral). Ovral is given as 2 tablets stat and then 2 more tablets 12 hours later. This regimen is close to 99% effective in preventing pregnancy when given within 72 hours. Ovral would be the most effective pharmacotherapy for this patient. There is a high incidence of nausea and vomiting with this regimen; antiemetics may be required.
Clomiphene (choice A) works as an anti-estrogen. It is used to increase FSH levels and induce ovulation in infertile patients. It is not used for postcoital contraception.
Gentamicin (choice B) is an IV antibiotic most commonly used against gram-negative organisms. This patient may be at risk for sexually transmitted disease (STD) given that the condom broke. It is important to discuss the issue of STD with the patient and to decide whether prophylactic antibiotics will be given. However, IV gentamicin is not used for antibiotic prophylaxis.
Labetalol (choice C) is an alpha-1- and nonselective beta-blocker. It is used commonly in pregnancy to treat hypertension. This patient has no history of hypertension. Her blood pressure is only mildly elevated and it is probably elevated during this visit because of anxiety. She should have follow-up blood pressure checks, but labetalol would not be indicated at this point.
Trimethoprim-sulfamethoxazole (choice E), also known as Bactrim, is used to treat infections. Among its most common uses is to treat urinary tract infections. As discussed above, this patient may require antibiotic prophylaxis because of her exposure. However, Bactrim is not typically used for STD prophylaxis. Furthermore, this patient has an allergy to sulfa drugs, which would make trimethoprim- sulfamethoxazole contraindicated.
A 42-year-old woman comes to the physician because of vaginal itch and discharge, dysuria, and dyspareunia. These symptoms have been steadily worsening over the past 3 days. Pelvic examination reveals an erythematous vagina and a thin, green, frothy vaginal discharge with a pH of 6. Microscopic examination of the discharge demonstrates the presence of a pear-shaped, motile organism. Which of the following is the most likely pathogen?
(A) Candida albicans
(B) Gardnerella vaginalis
(C) Herpes simplex virus
(D) Treponema pallidum
(E) Trichomonas vaginalis
Respuesta: E
The correct answer is E. This patient has the symptoms and signs most consistent with a Trichomonas vaginalis infection. Patients with T. vaginalis typically experience vaginal itch and discharge, dysuria, frequency and urgency of urination, and dyspareunia. with T. vaginalis will be asymptomatic. The key finding to diagnose However, a significant minority (around 20%) of patients infected the infection is the presence of motile, pear-shaped, flagellated organisms on the normal saline, wet-mount smear preparation. These organisms will be smaller than the surrounding vaginal epithelial cells but larger than white blood cells. The treatment for T. vaginalis is metronidazole.
Candida albicans (choice A) is a common cause of vaginitis. We know from the findings, however, that this patient does not have a Candida infection. Her discharge is not consistent with Candida infection. Candida typically causes a thick, white (“cottage-cheese”) discharge with a pH of 4 to 5. Also, microscopic examination demonstrates the organism T. vaginalis and not the pseudohyphae seen with a Candida infection.
Gardnerella vaginalis (choice B) is a common organism in bacterial vaginosis, in association with increased levels of anaerobic bacteria. The discharge in bacterial vaginosis can appear similar to that caused by T. vaginalis. However, bacterial vaginosis is usually characterized by a strong odor, and irritation of the vaginal epithelium is usually not seen. Furthermore, this patient has an identifiable organism on wet-mount.
Herpes simplex virus (choice C) infection is characterized by vesicles and ulcers and an extremely tender vulva and vaginal area. This patient has no vesicles or ulcers and has an obvious organism on wet-mount.
Treponema pallidum (choice D) is the organism that causes syphilis. Primary infection with T. pallidum is characterized by a painless chancre on the vulva, vagina, or cervix. The organism is identified on dark-field microscopy and not wet-mount preparation.
A 34-year-old woman, gravida 4, para 3 at 38 weeks’ gestation, comes to the labor and delivery ward because of contractions. Her prenatal course was significant for low maternal weight gain. She had a normal 18-week ultrasound survey of the fetus and normal 36- week ultrasound to check fetal presentation. Her blood type is O positive, and she is rubella immune. Three years ago, she had a multiple myomectomy. She takes prenatal vitamins and has no known drug allergies. She smokes one pack of cigarettes per day. Which of the following complications is most likely to occur?
(A) Amniotic fluid embolism
(B) Anencephaly
(C) Macrosomia
(D) Rh isoimmunization
(E) Uterine rupture
Respuesta: E
The correct answer is E. This patient, with a prior multiple myomectomy, would be at increased risk for uterine rupture. Uterine rupture is a rare, potentially catastrophic outcome in which there is complete separation of all layers of the uterine musculature. The most commonly cited risk factor is prior surgery involving the myometrium (e.g., prior c-section or myomectomy). However, uterine rupture may also be associated with blunt abdominal trauma, incorrect use of oxytocin, perforation with an intrauterine pressure catheter, grand multiparity, fetal malpresentation, or difficult delivery with forceps or breech extraction. The classic symptoms are severe abdominal pain with vaginal bleeding, although the presentation can vary. Fetal distress will often be found on electronic fetal monitoring. Management involves immediate laparotomy in cases where the suspicion for uterine rupture is high.
Amniotic fluid embolism (choice A) is a very rare but potentially fatal occurrence in obstetrics. It is believed to occur when a significant amount of amniotic fluid enters the maternal circulation. The classic presentation is with maternal respiratory distress, followed by cardiovascular collapse, hemorrhage, and coma. It is not clear what risk factors exist for the development of this syndrome, although some investigators have shown that many women with amniotic fluid embolism had allergy or atopy. This patient’s history would not place her at particular risk for this rare outcome.
Anencephaly (choice B) is a neural tube defect in which there is an absence of development of the cranium and cerebral hemispheres. The defect can be diagnosed by ultrasound. The fetus appeared normal at the 18- and 36-week ultrasounds and therefore would not be considered at risk for anencephaly.
Fetal macrosomia (choice C) is associated with maternal diabetes and obesity. This patient’s cigarette smoking puts her at greater risk for having a low birth weight infant.
This mother is not considered to be at risk for Rh isoimmunization (choice D), as she is Rh positive.
A 39-year-old woman, gravida 3, para 2 at 34 weeks’ gestation, with a known history of chronic hypertension, is found to have a blood pressure of 180/115 mm Hg at a routine prenatal visit. Her prenatal course had been otherwise unremarkable. She is transferred to the labor and delivery ward for further management. IV antihypertensive medications should be given to this patient with a goal of which of the following blood pressures?
(A) 90/60 mm Hg
(B) 100/75 mm Hg
(C) 120/80 mm Hg
(D) 150/95 mm Hg
(E) 180/110 mm Hg
Respuesta: D
The correct answer is D. The management of an acute hypertensive episode during pregnancy presents a challenge. On the one hand, it is important to lower the blood pressure of the mother to prevent the development of a hypertensive emergency (e.g., hypertensive encephalopathy, cardiac decompensation, or damage to other organs). Extreme hypertension is also a risk for placental abruption. On the other hand, lowering the blood pressure too much may lead to underperfusion of the placenta and fetal distress. The goal of antihypertensive therapy during an acute episode of severe hypertension is not to lower the blood pressure to normotensive levels but rather to a mild-moderate hypertensive level, with a diastolic blood pressure of 90-100 mm Hg. In this patient, 150/95 mm Hg is a good target blood pressure.
Blood pressures of 90/60 mm Hg (choice A) or 100/75 mm Hg (choice B) are too low. Lowering the maternal blood pressure to this level could lead to hypoperfusion of the placenta and fetal distress.
A blood pressure of 120/80 mm Hg (choice C) is normal for nonpregnant patients. However, acutely lowering this patient’s blood pressure from 180/115 mm Hg to 120/80 mm Hg could lead to fetal distress.
A blood pressure of 180/110 mm Hg (choice E) is too high to use as a goal for antihypertensive therapy. A level of 150/95 mm Hg represents the best compromise between too high versus too low in a chronically hypertensive pregnant patient.
A 33-year-old woman comes to the physician because she has not had a menstrual period for 6 months. Prior to this she had a normal period every 29 days that lasted for 4 days. She has noted some weight gain in the past few months. She has a history of hepatitis A infection 6 years ago and had an appendectomy at age 12. She takes no medications and has no allergies to medications. Her father died of acute pancreatitis 3 years ago. Her mother is alive and well with no medical problems. Which of the following is the most appropriate next step in diagnosis?
(A) Amylase
(B) FSH
(C) β-hCG
(D) Liver function tests
(E) TSH
Respuesta: C
The correct answer is C. The first step in the diagnosis of secondary amenorrhea is a pregnancy test. Secondary amenorrhea is defined as the cessation of menses for 3 months in a woman with previously regular periods or 6 months in a woman with a history of oligomenorrhea. This patient had normal periods up until the last 6 months. The most common cause of secondary amenorrhea in a 33- year-old with previously normal cycles is pregnancy. Therefore, β- hCG would be indicated as the first step.
Amylase (choice A) is a useful laboratory value to check in cases in which pancreatitis is on the differential diagnosis. The fact that this patient’s father died of pancreatitis almost certainly has no relationship to her current amenorrhea.
FSH (choice B) is a useful test in women with secondary amenorrhea after a pregnancy test, TSH, and prolactin have been checked, and after the patient’s estrogen status is assessed with a progesterone withdrawal test. If the patient is found to be amenorrheic from estrogen deficiency, assessment of the FSH level allows one to distinguish between a centrally mediated deficiency (FSH low) and an ovarian deficiency (FSH high).
Liver function tests (choice D) would not be indicated in this patient as part of her workup for secondary amenorrhea. Hepatitis A is a virus that affects hepatocytes and can cause abnormal liver function tests. However, it does not cause chronic infection and almost certainly is not causing this patient’s secondary amenorrhea.
TSH (choice E) is an excellent test in the workup of secondary amenorrhea after pregnancy has been ruled out. Women with abnormal thyroid function can have menstrual irregularities, so a TSH is a good test for any woman with abnormal menses. However, a pregnancy test should still be done first in the evaluation of secondary amenorrhea.
A 24-year-old woman, gravida 2, para 2, comes to the physician for a yearly physical and birth control counseling. She is currently using the rhythm method of birth control, but has heard that this method has a high failure rate and would like to try a different method. Several of her friends use the intrauterine device (IUD), and she is wondering whether she could also use this method. Past medical history is significant for eczema. Past surgical history is significant for a right ovarian cystectomy 2 years ago. Past gynecologic history is significant for multiple episodes of Chlamydia cervicitis and two episodes of pelvic inflammatory disease (PID), the most recent episode occurring 1 year ago. She takes acetaminophen for occasional tension headaches. She is allergic to penicillin. She smokes one-half pack of cigarettes per day. Physical examination is unremarkable. Which of the following would be the best recommendation for this patient regarding her birth control method?
(A) “The IUD is absolutely contraindicated.”
(B) “The IUD is recommended.”
(C) “The IUD is recommended if cervical cultures are negative.”
(D) “The oral contraceptive pill is absolutely contraindicated.”
(E) “The rhythm method is recommended.”
Respuesta: A
The correct answer is A. Active, recent, or recurrent sexually transmitted diseases (STDs) are considered an absolute contraindication to intrauterine device (IUD) use. This patient has a gynecologic history that is significant for multiple episodes of chlamydia cervicitis and two episodes of pelvic inflammatory disease (PID). In a patient with an IUD in place, these infections have an increased likelihood of causing significant morbidity and mortality. Many physicians consider even the risk for STDs (i.e., multiple sexual partners or sexual relations with someone with multiple sexual partners) to be a contraindication to IUD use. The presence of such numerous and recent episodes of STDs would certainly make the IUD absolutely contraindicated for this patient.
The IUD is contraindicated, not recommended (choice B), for the reasons given above. The IUD would not be recommended if cervical cultures were negative (choice C) for two reasons. First, cervical cultures have a high false negative rate. Therefore, even if the cultures are negative, it does not completely rule out an infection. Second, even if the cultures are truly negative this time, her recent history of multiple STDs places her at far too great a risk to be a candidate for the IUD.
The oral contraceptive pill is not absolutely contraindicated and therefore would not be a correct recommendation to make to this patient (choice D). The pill is absolutely contraindicated in women older than 35 who smoke; however, this patient is 24 years old. She should certainly be encouraged to stop smoking, and smoking cessation advice and counseling should be offered to her.
The rhythm method would not be a correct recommendation for this patient (choice E). Even with perfect use, the rhythm method has a failure rate of greater than 10%. Furthermore, because of the nature of the technique, the actual failure rate is significantly higher, probably greater than 30%. The rhythm method is not recommended as a first-line birth control option.
