OB/Gyn: UWorld

Question 1

What disorder is characterized by a patient with a blind ended vaginal pouch with little or no uterine tissue and a XX genotype?

Answer 1

Mullerian agenesis

The differential diagnosis for a patient with a female phenotype but lacking a normal vagina and uterus includes mulerian agenesis, androgen insensitivity, and 5-alpha-reductase deficiency. Of these, only mullerian agenesis is characterized by an XX genotype.

Question 2

What is the first-line medication for the treatment of hypertension in pregnancy?

Answer 2

Methyldopa

Methyldopa is a pregnancy category B agent.

Question 3

Large genital warts (lesions) can be treated with what?

Answer 3

Excision or fulguration (electric current)

Regardless of the method of treatment, rates of recurrence are high.

Question 4

What happens to total T4 and TSH during pregnancy?

Answer 4

Total T4 increases but TSH stays the same

Increased estrogen during pregnancy leads to an increase in thyroid binding globulin (TBG) which results in an increase in TBG-bound T3 and T4. Thus total T4 and T3 are increased, but free T4 and T3 remain normal so TSH also remains normal.

Question 5

Patients with what diagnosis present with primary amenorrhea and anosmia?

Answer 5

Kallmann’s syndrome

They have a normal female karyotype and will have laboratory findings consistent with GnRH deficiency (low FSH and LH).

Question 6

A finding of atypical squamous cells of undetermined significance on cytology in a patient aged between 21 and 24 years is managed how?

Answer 6

Repeat cytology in 1 year

In this young patient population, HPV infection is transient and malignant transformation is rare. For this reason, colposcopy is not performed unless the patient demonstrates ASC3 on 3 consecutive pap smears. However, colposcopy is recommended for any ASC-H, atypical glandular cells, or high-grade squamous intraepithelial lesion.

Question 7

What is characterized clinically by a fever and uterine tenderness in the postpartum period and is often associated with foul-smelling lochia

Answer 7

Endometritis

• Risk factors include prolonge rupture of membranes (ROM), prolonged labor, operative vaginal delivery, and C-section.*
• Broad spectrum antibiotics are required to treat this typically polymicrobial infection*.

Question 8

Female offspring of women who ingested diethylstilbestrol during pregnancy are at increased risk of developing what?

Answer 8

Clear cell adenocarcinoma of the vagina and cervix

As well as cervical anomalies (hypoplasia) and uterine malformations (T-shaped/small uterine cavity), vaginal adenosis, and vaginal septae. Many have difficulty conceiving and maintaining pregnancy.

Question 9

Multinucleated giant cells and a vesicular rash seen on genital exam are characteristic of what?

Answer 9

Genital herpes

Question 10

What is the treatment of choice for postpartum endometritis?

Answer 10

IV clindamycin and IV gentamicin

Question 11

In what phase of the menstrual cycle is cervical mucus thicker, less stretchable, and inhospitable to sperm?

Answer 11

The mid- and late-luteal phase

Question 12

What is the most commonly identified infectious agent associated with fetal growth restriction (FGR)?

Answer 12

Cytomegalovirus (CMV)

This can not be effectively prevented or treated in most cases.

Question 13

How many days after unprotected intercourse can levonorgestrel be given?

Answer 13

5 days (120 hours)

Levonorgestrel = Plan B

Question 14

Which vaginitis/vaginosis is characterized by inflammation, pruritus, and a thin malodorous vaginal discharge?

Answer 14

Trichomonas vaginitis

In contrast, bacterial vaginosis does not cause inflammation, and candida vaginitis causes a discharge that is thick and white.

Question 15

What is the most appropriate infertility treatment for a patient with premature ovarian failure who wants to get pregnant?

Answer 15

In vitro fertilization with donor oocytes

Question 16

Estrogen replacement therapy affects the metabolism of what other hormone?

Answer 16

Thyroid hormone

The requirement for L-thyroxine increases when estrogen replacement therapy is started. Pregnancy also increases thyroid hormone requirements and patients should be monitored every 4-6 weeks for dose adjustments.

Question 17

During which phase of the menstrual cycle is the cervical mucus profuse, clear, and thin, and will stretch to approximately 6cm and exhibit ferning on a microscope slide smear preparation?

Answer 17

The ovulatory phase

Question 18

What is the standard of care for a threatened abortion?

Answer 18

Reassurance and outpatient follow up in 1 week for repeat ultrasonogram

Bed rest and abstaining from sexual intercourse are usually recommended because this will prevent any feelings of guilt on the part of the parents in the case that pregnancy is actually lost, however, there is no evidence of the benefit of these interventions on the outcome.

Question 19

What is the next step in working up a patient with bilateral guaiac-negative nipple discharge?

Answer 19

Workup includes ruling out pregnancy, measuring serum prolactin and TSH levels, and possibly an MRI of the brain to rule out prolactinoma

Prolactinoma, hypothyroidism, overstimulation of the nipple, oral contraceptice pills, and medications which lower dopamine levels are common causes of galactorrhea.

Question 20

Women affected by polycystic ovarian syndrome (PCOS) are at increased risk of what cancer?

Answer 20

Endometrial hyperplasia and carcinoma

Women with PCOS are oligo- or an-ovulatory and are deficient in progesterone secretion; thus, they usually have a constant and unbalanced mitogenic stimulation of the endometrium by estrogens leading to endometrial hyperplasia, intermittent breakthrough bleeding and dysfuntional uterine bleeding. This unopposed estrogen stimulation leaves them at increased risk for endometrial cancer.

Question 21

What is the diagnosis for a newborn with a small body size, microcephaly, digital hypoplasia, nail hypoplasia, midfacial hypoplasia, hirsutism, cleft palate and rib anomalies?

Answer 21

Fetal hydantoin syndrome

Caused by maternal phenytoin or carbamazepine use during pregnancy

Question 22

Patients with what diagnosis present with primary amenorrhea, nondeveloped internal reproductive organs, a normal XX karyotype, normal female levels of testosterone, and normal axillary and pubic hair development?

Answer 22

Mullerian agenesis

Question 23

45 XO is the genotype found in patients with what diagnosis?

Answer 23

Turner syndrome

These patients have primary amenorrhea, but the FSH level is generally elevated due to primary ovarian failure.

Question 24

What two tests are used to screen for syphilis?

Answer 24

Nontreponemeal serologic tests: Venereal Disease Research Laboratory (VDRL) and Rapid Plasma Reagin (RPR)

Question 25

What is the recommended management of a patient with an active genital herpetic lesion who is in active labor?

Answer 25

Immediate C-section

Neonatal HSV is a severely morbid and potentially fatal illness

Question 26

What is the most common preventable cause of fetal growth restriction in the United States?

Answer 26

Cigarette smoking

1 in 3 cases of FGR is attributable to smoking, and women who smoke while pregnant have a 3 to 4-fold increased risk of having a growth restricted infant.

Question 27

Infants born to patients with Graves disease treated with surgery are at risk for what?

Answer 27

Thyrotoxicosis

This would occur because of the passage thyroid stimulating immunoglobulin across the placenta. Thyroid stimulating immunoglobulin remains as high as 500 times the normal value for several months following thyroidectomy.

Question 28

What are the 3 hallmark features of endometriosis?

Answer 28

1. Dyspareunia
2. Dysmenorrhea
3. Dyschezia

Other features include pelvic pain and infertility. Treatment options include combined oral contraceptives, GnRH analogs (IE Leuprolide), and danazol

Question 29

How does hyperprolactinemia cause amenorrhea?

Answer 29

Elevated prolactin levels suppress GnRH release thereby suppressing LH and FSH production and ovulation. This is the reason for anovulation and amenorrhea in lactating mothers

Question 30

What is the treatment of choice for treating a deep vein thrombosis (DVT)?

Answer 30

Anticoagulation with heparin

Question 31

What test is necessary to confirm the diagnosis of missed abortion?

Answer 31

Transvaginal ultrasound

Question 32

What is the most important intervention for preventing spread of HIV from mother to fetus?

Answer 32

Zidovudine to the mother throughout pregnancy and labor, as well as to the neonate for the first 6 weeks of life

Question 33

All pregnant women should have an oral glucose tolerance test at what gestational age of pregnancy?

Answer 33

24 to 28 weeks gestation

High-risk patients (markedly obese, family history of diabetes) can be screened earlier in pregnancy.

Question 34

What can be used to differentiate symmetric from asymmetric fetal growth restriction (FGR)?

Answer 34

Head to abdomen circumference ratio

Question 35

What is the preferred form of hormonal contraception for lactating mothers?

Answer 35

Progestin-only oral contraceptives

Question 36

What is the first step in management of a pregnant patient who presents with vaginal bleeding and hemodynamic instability?

Answer 36

Obtain venous access (with two large bore needles)

Maintainance of airway, breathing, and circulation is always the first priority in any patient presenting for emergent care. C-section may later be needed if the patient continues to be unstable.

Question 37

What should be performed early in the evaluation of an infertile couple, usually as the initial screening test?

Answer 37

Semen Analysis

Male factor accounts for 20-30% of infertility cases.

Question 38

What is indicated for a patient with polycystic ovarian syndrome (PCOS) and impaired glucose tolerance?

Answer 38

Metformin

Metformin is indicated in PCOS patients with impaired glucose tolerance becuase it helps in preventing type 2 diabetes mellitus as well as improving obesity, hirsutism, menstrual irregularity, and infertility.

Question 39

Idiopathic central precocious puberty is managed with GnRH agonist therapy in order to prevent what?

Answer 39

Premature fusion of the epiphyseal plates

This would otherwise lead to a short stature.

Question 40

Hypotension is a common side effect of epidural anesthesia. What is the mechanism of this effect?

Answer 40

Blood redistribution to the lower extremities and venous pooling

Question 41

Hyperemesis gravidarum presents with severe and persistent vomiting, weight loss, and what?

Answer 41

Ketonuria

Question 42

Does the use of combination oral contraceptive pills cause weight gain?

Answer 42

No

Numerous recent studies have determined that weight gain is not associated with the use of combination oral contraceptives. Weight gain has been reported with medroxyprogesterone use but controlled studies have not been done to substantiate this effect.

Question 43

Post-term pregnancies are at an increased risk for what?

Answer 43

Oligohydramnios

This is associated with increased fetal morbidity. Post-term pregnancies should be monitored for oligohydramnios twice weekly.

Question 44

What is considered first-line therapy for lichen sclerosus?

Answer 44

High-potency topical steroids

Question 45

What most commonly affects postmenopausal women and manifests with vulvar pruritus and discomfort? Exam shows porcelain-white atrophy.

Answer 45

Lichen sclerosus

Biopsy should be considered to rule out vulvar squamous cell carcinoma.

Question 46

How long after infection with Treponema pallidum before the patient develops a painless papule at the site of inoculation?

Answer 46

2-3 weeks after infection

If left untreated, the chancre of primary syphilis heals spontaneously within one to three months.

Question 47

Human chorionic gonadotropin (hCG) is secreted by what?

Answer 47

Syncytiotrophoblast

Question 48

Patients with what diagnosis present with amenorrhea, normally developed breasts, absent pubic and axillary hair, absent internal reproductive organs, and a 46 XY karyotype?

Answer 48

Androgen resistance

In this condition, serum testosterone levels are in a range typical for males. The internal reproductive organs do not develop because the testes are still present and secrete mullerian inhibiting factor.

Question 49

What is a common cause of recurrent mid trimester abortions?

Answer 49

Cervical incompetence

Question 50

Isotretinoin is associated with what congenital abnormalities?

Answer 50

1. Craniofacial dysmorphism
2. Heart defects
3. Deafness

Question 51

1. What stimulates prolactin secretion?
2. What inhibits prolactin secretion?

Answer 51

1. Serotonin and TRH stimulate prolactin
2. Dopamine inhibits prolactin

Hypothyroidism results in elevated TSH and TRH levels and can subsequently cause hyperprolactinemia.

Question 52

What is caused by increased levels of prostaglandins and presents with lower abdominal pain that occurs with mestruation?

Answer 52

Primary dysmenorrhea

NSAIDS and oral contraceptive pills can be used to improve symptoms.

Question 53

Bleeding is seen in what percent of placental abruptions?

Answer 53

80%

Question 54

What is the treatment of choice for a patient with pelvic inflammatory disease (PID) who cannot take oral medication because of nausea and vomiting?

Answer 54

Hospitalization and Inpatient treatment with cefotetan and doxycycline

IV Clindamycin/gentamicin can also be given

Question 55

What is the treatment for vaginismus?

Answer 55

Relaxation, Kegel exercises (to relax vaginal muscles), and insertion of objects of gradually increasing size to encourage desensitization

Question 56

What is characterized by a patient with a male genotype, female external genitalia, and virilization typically occurring at puberty?

Answer 56

5-alpha-reductase deficiency

Question 57

What occurs most frequently in women above age 40 and typically presents with secondary dysmenorrhea and menorrhagia? Physical examination will reveal an enlarged and generally symmetrical uterus.

Answer 57

Adenomyosis

Question 58

What is the next step in management of a patient with uniductal and guaiac positive nipple discharge?

Answer 58

Cytologic examination

This allows the pathologist to examine cells from the duct to distinguish carcinoma, proliferative changes, and inflammatory processes. Cytology is not indicated for guaiac negative discharge.

Question 59

What is the best test for detection of fetal chromosomal abnormalities in the first trimester of pregnancy?

Answer 59

Chorionic villus sampling

It can be done between 10 and 12 weeks of gestations thus offering the advantage of an early diagnosis. Amniocentesis is done between the 16th and 18th week of gestation.

Question 60

How does one screen for gestational diabetes?

Answer 60

One hour 50 gram oral glucose tolerance test between 24 and 28 weeks gestation

After 1 hour, if glucose value is 140 mg/dL, a 3 hour oral glucose tolerance test is administered to confirm the diagnosis of gestational diabetes.

Question 61

External cephalic version can be attempted in women with breech pregnancies at what Gestational age?

Answer 61

Greater than 37 weeks

If there are no contraindications to vaginal delivery and fetal well-being has been established.

Question 62

In a pregnant patient, symmetrical pitting edema of both calves with no calf tenderness and in the absence of any other signs/symptoms/abnormalities is most likely due to what?

Answer 62

Benign edema of pregnancy

Preeclampsia and DVT should also be considered, but are unlikely in the absence of other classic symptoms of these conditions.

Question 63

Why are initial menstrual cycles in pubertal females usually irregular and often anovulatory?

Answer 63

Immaturity of the developing hypothalamic-pituitary-gonadal axis

Inadequate production of of LH, FSH and other hormones required to induce ovulation.

Question 64

What is the earliest sign of magnesium sulfate toxicity?

Answer 64

Depression of the deep tendon reflexes

Question 65

What are 5 signs of chorioamnionitis?

Answer 65

1. Maternal fever
2. Leukocytosis
3. Uterine tenderness
4. Maternal tachycardia
5. Fetal tachycardia

Question 66

What test is used to confirm the diagnosis of syphilis?

Answer 66

1. Treponemal serologic test: Fluorescent treponemal antibody Absorption test (FTA-ABS)
2. Darkfield Microscopy

Question 67

Why do obese women have milder menopause symptoms?

Answer 67

Increased peripheral conversion of androgens to estrogen

The major source of estrogen in menopausal women is from the peripheral conversion of adrenal androgens by the aromatase enzyme present in adipose tissue. This process is increased in obese women.

Question 68

Multiple painful vesicles in the genital region following a prodrome of burning and pruritus is characteristic of what diagnosis?

Answer 68

Herpes genitalis

This is differentiated from chancroid which presents as deep, painful ulcers with a purulent base and painful lymphadenopathy.

Question 69

What is the most likely cause of infertility in a patient with polycystic ovarian syndrome (PCOS)?

Answer 69

Anovulation

Question 70

What is the most common risk factor for placental abruption?

Answer 70

Maternal hypertension

Question 71

Painful genital ulcers with a deep, purulent base and painful lymphadenopathy are characteristic of what diagnosis?

Answer 71

Chancroid caused by infection with haemophilus ducreyi

This is differentiated from herpes genitalis which presents with multiple vesicles following a prodrome of burning and pruritus.

Question 72

What is the treatment for intrahepatic cholestasis of pregnancy?

Answer 72

Ursodeoxycholic acid: increases bile flow and can relieve pruritus

Hydroxyzine and cholestyramine are alternative therapies, though they are less effective and can have concerning side effects.

Question 73

A finding of atypical squamous cells of undetermined significance on cytology in a patient aged 25 years or greater is managed how?

Answer 73

Human Papillomavirus (HPV) DNA test

Those who test positive for HPV require colposcopy. Patients with a negative HPV test can be followed with repeat pap smear and HPV test in 3 years.

Question 74

FSH elevation in the setting of _>_3 months of amenorrhea in a woman under age 40 confirms what diagnosis?

Answer 74

Premature ovarian failure

Question 75

What is the next step in management if maternal serum alpha-fetoprotein (MSAFP) levels are abnormal in a pregnant patient?

Answer 75

Ultrasonography

This is done to confirm gestational age, detect fetal structural anomalies, detect multiple gestation, and confirm a viable pregnancy.

Question 76

What is the treatment for moderate or severe atrophic vaginitis?

Answer 76

Local estrogen therapy

Question 77

What is the treatment of choice for bacterial vaginosis in a pregnant woman?

Answer 77

Oral metronidazole

Oral metronidazole is the treatment of choice for bacterial vaginosis regardless of pregnancy status.

Question 78

The Center for Disease Control recommends that all pregnant women without contraindications be vaccinated against what?

Answer 78

Influenza

Question 79

What happens to Inhibin levels in a patient with Turner syndrome?

Answer 79

Inhibin is decreased

Inhibin is a marker of ovarian function which is reduced in Turner syndrome.

Question 80

Aortic coarctation presents with elevated blood pressure in the upper extremities but low blood pressure in the lower extremities and is a common finding in what syndrome?

Answer 80

Turner syndrome

Patients with Turner syndrome have ovarian dysgenesis and poor ovarian function.

Question 81

Bilateral breast tenderness and swelling that presents 24-72 hours post partum and peaks 3-5 days after delivery before resolving spontaneously is most likely due to what?

Answer 81

Breast engorgement

This is a common problem associated with breast feeding.

Question 82

What complication of intrauterine fetal demise should be suspected when serum fibrinogen levels are borderline or low?

Answer 82

Disseminated intravascular coagulation

Induction of labor is the most appropriate next step in management.

Question 83

What is the next step in working up a patient with primary amenorrhea who is shown to have a uterus on ultrasound?

Answer 83

Measure serum FSH

1. If increased: Proceed to karyotyping
2. If decreased: Proceed to cranial MRI

Question 84

Why is erythromycin not used to treat Syphillis (treponema pallidum) in a pregnant patient?

Answer 84

Erythromycin is effective against T. Pallidum but it cannot cross the placenta and is therefore ineffective in treating pregnant patients

Penicillin is considered to be the treatment of choice for pregnant patients with syphilis. If a patient is allergic to penicillin, the allergy should be confirmed with skin testing and the patient should then undergo desensitization so that she can safely take the medication.

Question 85

What is the first-line therapy for the majority of patients with premenstrual syndrome (PMS)?

Answer 85

Selective serotonin reuptake inhibitors

Premenstrual dysphoric disorder (PMDD) is a severe variant of PMS, with prominent irritability and anger.

Question 86

What is the gold standard for evaluation the cervix for cervical incompetence in pregnancy?

Answer 86

Transvaginal ultrasound

A cervical length below the 10th percentile for gestational age is considered a short cervix. This includes cervices less than 25 mm at gestational age 23-28 weeks

Question 87

What is the gold standard for diagnosing endometriosis?

Answer 87

Laparoscopy

Question 88

Why are fluoroquinolones contraindicated during pregnancy?

Answer 88

They can potentially cause arthropathy in the unborn fetus

Question 89

What is the most commonly identified risk factor for placental abruption?

Answer 89

Hypertension

Other risk factors include:

1. Prior placental abruption
2. Cocaine
3. Alcohol
4. Tobacco
5. Vascular diseases such as diabetes and SLE

Question 90

Why is Trimethoprim-Sulfamethoxazole contraindicated in the first and third trimesters?

Answer 90

1st Trimester: Interferes with folic acid metabolism

3rd Trimester: Increases risk of kernicterus (bilirubin-induced brain dysfunction) in the newborn

Question 91

What causes thrombocytopenia and hemolytic anemia in a pregnant patient with normal PT and PTT, but also usually causes renal failure and is not necessarily associated with preeclampsia?

Answer 91

Hemolytic uremic syndrome (HUS)

This is differentiated from HELLP syndrome which does not cause renal failure and is associated with preeclampsia.

Question 92

When do amniotic fluid embolisms usually occur?

Answer 92

During amniocentesis or during labor

Question 93

Up to what percent of females being evaluated for infertility are found to have endometriosis?

Answer 93

30%

Patients with endometriosis are at an increased risk of decreased fertility or infertility.

Question 94

What is the treatment of choice for candida vulvovaginitis?

Answer 94

An azole antifungal such as oral fluconazole

Topical Nystatin can also be used.

Question 95

A patient in the last 4-8 weeks of pregnancy who presents with irregular contractions felt in the lower abdomen that do not occur at shortening intervals or with increasing intensity is most likely experiencing what?

Answer 95

False labor

In false labor, progressive cervical changes are absent, contractions are irregular and discomfort is readily relieved by sedation. All such patients need reassurance.

Question 96

Maternal factors such as hypertension, smoking, hypoxia, vascular disease, and preeclampsia are typical causes of what kind of intrauterine growth restriction (IUGR)?

Answer 96

Asymmetric IUGR

Asymmetric IUGR is a result of a late exposure to a maternal factor that does not allow optimal fetal growth. It is characterized by a normal or almost normal head size and a reduced abdominal circumference.

Question 97

Why is magnesium sulfate given to an eclamptic patient?

Answer 97

Prevent further development of seizures while delivery of the fetus is accomplished

Eclamptic seizures are of very short duration (few seconds) so magnesium sulfate infusions are mainly to prevent the further development of seizures rather than controlling current seizures.

Question 98

What is a chronic condition associated with pelvic pain worsened by bladder filling or intercourse accompanied by urinary frequency, urgency and nocturia?

Answer 98

Interstitial cystitis (Painful bladder syndrome)

Question 99

Failure to lactate in Sheehan’s syndrome is due to what hormonal change?

Answer 99

Prolactin deficiency

Hormones secreted from the anterior pituitary include prolactin, thyroid stimulating hormone (TSH), and follicle stimulating hormone (FSH).

Question 100

What is a normal biophysical (BPP) profile score?

Answer 100

8-10

Repeat BPP once or twice weekly until term for high risk pregnancies.

Question 101

After pregnancy has been excluded, what 3 lab levels should be checked during initial workup of amenorrhea?

Answer 101

1. FSH to rule out ovarian failure
2. Prolactin to evaluate for hyperprolactinemia
3. TSH to evaluate for hypothyroidism

Question 102

In postmenopausal women, the initial workup of an adnexal mass should include what 2 components?

Answer 102

1. Transvaginal ultrasound
2. Serum cancer antigen (CA-125) level

Question 103

Polycystic ovarian syndrome is a common cause of amenorrhea due to anovulation. What is another common cause of anovulatory amenorrhea?

Answer 103

Obesity

FSH and LH levels are usually normal.

Question 104

Why is Doxycycline and other tetracyclines contraindicated in pregnancy?

Answer 104

They interfere with bone and tooth development

Children exposed to tetracycline in utero often have gray teeth. They should not be used in the second half of pregnancy or in children

Question 105

What is the management of choice for a patient with severe dysfunctional uterine bleeding (DUB) or a patient with moderate DUB but with active bleeding?

Answer 105

Estrogen

High dose estrogen for uncontrolled bleeding.

Question 106

Jaundice in the third trimester with marked pruritis and elevated serum total bile acid concentrations are suggestive of what?

Answer 106

Intrahepatic cholestasis of pregnancy

Pruritus is especially significant on the palms and soles and worsens at night.

Question 107

What test should be carried out if fetal movement decreases or becomes imperceptible by the mother?

Answer 107

A non-stress test (NST) to document fetal well-being

In the presence of decreased fetal movements, fetal compromise should be suspected, and the best next step in management is a non-stress test. NST is usually performed in high-risk prenancies starting at 32-34 weeks gestation or when there is a loss of perception of fetal movements in any pregnancy.

Question 108

What is the appropriate next step in managing a patient that is less than 37 weeks pregnant with a fetus in breech presentation?

Answer 108

Routine follow-up

Breech presentations often convert to vertex before the 37th week.

Question 109

What is human chorionic gonadotropin (hCG) mainly responsible for?

Answer 109

The preservation of the corpus luteum in early pregnancy

Question 110

What can sometimes be seen in patients with systemic lupus erythematosus (SLE) and is a potential cause of recurrent pregnancy loss due to thrombus development within the placenta?

Answer 110

Lupus anticoagulant

Question 111

Why is the incidence of carpal tunnel syndrome increased during pregnancy?

Answer 111

Estrogen-mediated depolymerization of ground substance causes interstitial edema in the hands (and face) and thus increases pressure within the carpal tunnel

Question 112

When should a pregnant woman be tested for group B strep colonization?

Answer 112

35-37 weeks

• Women who are colonized with GBS receive prophylactic antibiotics (penicillin or ampicillin) at the time of delivery.*
• Women who have had GBS bacteriuria during pregnancy or who have previously delivered a child that developed an early-onset GBS infection are automatically given prophylactic antibiotics regardless of the results of a rectovaginal culture.*

Question 113

Postpartum endometritis is most commonly caused by what bacteria?

Answer 113

Polymicrobial infection

Composed of gram positive and gram negative organisms, aerobic and anaerobic organsims and occasionaly other organisms.

Question 114

What 2 treatments can induce ovulation in a patient with polycystic ovarian syndrome (PCOS)?

Answer 114

1. Clomiphene citrate
2. Metformin

Question 115

What is the treatment for magnesium sulfate toxicity?

Answer 115

Administration of calcium gluconate

Also, magnesium sulfate administration must be stopped.

Question 116

What is the next step in management of a woman with HELLP syndrome at 34 weeks of gestation?

Answer 116

Induction of labor

Prior to 34 weeks or lung maturity, steroids can be considered to promote lung maturity prior to delivery, contingent on the mother and fetus being stable.

Question 117

What otherwise abnormal findings are normal in the immediate postpartum period?

Answer 117

1. Low-grade fever
2. Leukocytosis
3. Vaginal discharge (initially bloody, then serous, and finally white to yellow in color days following delivery)

Question 118

Painless genital ulcers with a red and beefy base, and no associated lymphadenopathy, that do not resolve without antibiotic treatment are characteristic of what diagnosis?

Answer 118

Granuloma inguinale (Donovanosis) caused by Klebsiella granulomatis

This differs from primary syphilis which will resolve without antibiotics

Question 119

Abdominal pain in a young female in the middle of her cycle with a benign history and clinical examination is most likely what?

Answer 119

Mittelschmerz (midcycle pain)

This is common in women with regular menstrual periods who are not taking birth control pills (women who are ovulating).

Question 120

How is the management of hypothyroidism affected by pregnancy?

Answer 120

Levothyroxine dose must be increased

This increased levothyroxine requirement occurs mostly during the first trimester.

Question 121

What effect does primary ovarian failure have on FSH, LH, and the FSH/LH ratio?

Answer 121

1. FSH: Increased
2. LH: Increased
3. FSH/LH: >1

The elevation of FSH is generally greater than that of LH becuase of the slower clearance of FSH from the circulation.

Question 122

Multinucleated giant cells on Tzanck smear are characteristic of what?

Answer 122

Herpes and Varicella

Question 123

Bilateral solid ovarian masses discovered incidentally in a multiparous African-American pregnant woman most likely signify what

Answer 123

A pregnancy luteoma

This is a benign self-limited condition and requires no treatment.

Question 124

What causes gestational maternal virilization and virilization of XX fetuses leading to affected girls with normal internal genitalia with ambiguous external genitalia?

Answer 124

Congenital aromatase deficiency

Loss of peripheral conversion of androgens to estrogens.

Question 125

In pregnant patients, asymptomatic bacteriuria is treated with what?

Answer 125

7-day course of nitrofurantoin, amoxicillin, or a first-generation cephalosporin

Shorter courses (3 days for example) are ineffective at eradicating asymptomatic bacteriuria of pregnancy.

Question 126

What is indicated in cases of dysfunctional uterine bleeding (DUB) in women >35 years old?

Answer 126

Endometrial biopsy

This is also indicated in cases of DUB if hypertension, diabetes, or obesity are present.

Question 127

What is the first step in management of a patient suspected of having an amniotic fluid embolism presenting as abrupt onset hypoxia with respiratory failure, cardiogenic shock, and DIC?

Answer 127

Intubation and mechanical ventillation

Respiratory support is always the first step in management.

Question 128

What pregnancy-associated disorder is characterized by markedly elevated alkaline phosphatase and cholesterol levels in conjunction with intense pruritis?

Answer 128

Primary biliary cirrhosis

Question 129

What asymptomatic heart condition frequently becomes symptomatic in pregnancy?

Answer 129

Mitral stenosis (typically due to rheumatic heart disease)

Affected women often become symptomatic during pregnancy because of the physiologically increased total blood volume.

Question 130

What presents similarly to mastitis but lacks a fever and systemic symptoms?

Answer 130

Plugged ducts

Treatment is by improving the quality of breastfeeding. Persistently plugged ducts resulting in a galactocele may be treated with aspiration.

Question 131

What is the most likely cause of right upper quadrant pain in a pregnant patient with severe preeclampsia?

Answer 131

Distention of the liver (Glisson’s) capsule

Centrilobular necrosis, hematoma formation and the formation of thrombi in the portal capillary system can all cause swelling of the liver with destention of the Glisson’s capsule. This results in right upper quadrant pain as the peritoneum is innervated by somatic nerves that provide localized sensation of pain.

Question 132

A biophysical profile score of 2 or less is consistent with what?

Answer 132

Severe fetal asphyxia

For any biophysical profile score of 4 or less, delivery is indicated if the fetus is greater than 26 weeks gestational age.

Question 133

An antepartum hemorrhage with fetal heart changes progressing from tachycardia to bradycardia and finally to a sinusoidal pattern occurring suddenly after rupture of membranes suggests the diagnosis of what?

Answer 133

Vasa previa

The bleeding in this setting is fetal in origin, so maternal vital signs will remain stable while the fetus exsanguinates. When this condition is diagnosed, the treatment is an immediate caesarian section delivery (crash c-section).

Question 134

What is the most appropriate next step in management of a pregnant patient at 32 weeks gestation who has mild preeclampsia?

Answer 134

Bed rest at home with frequent follow-up

Question 135

The combination of thrombocytopenia, microangiopathic hemolytic anemia, and increased liver enzymes in a patient with preeclampsia is defined as what?

Answer 135

HELLP syndrome

Question 136

What should you suspect in a post-menopausal female with symptoms of vaginal dryness and dysuria, and physical exam findings of pale, dry vaginal mucosa, diminished labial fat pad, and scarce pubic hair?

Answer 136

Atrophic vaginitis

Moderate and severe cases require local estrogen therapy.

Question 137

The combination of primary amenorrhea, bilateral inguinal masses, and breast development without pubic or axillary hair is strongly suggestive of what diagnosis?

Answer 137

Androgen insensitivity syndrome

A blind vaginal pouch and a karyotype of 46 XY are other clues.

Question 138

Steroid treatment is effective at accelerating lung maturity and should be used at what stage of pregnancy?

Answer 138

Between 24 and 34 weeks

Question 139

Pregnant women with asymptomatic bacteriuria should be treated with antibiotics. Which antibiotics are most appropriate?

Answer 139

First line antibiotics for asymptomatic bacteriuria during pregnancy include:

1. Amoxicillin
2. Nitrofurantoin
3. Cephalexin

Question 140

At the first prenatal visit, what should be performed?

Answer 140

Blood typing and Rh antibody testing (in Rh (D) negative women)

Question 141

Tzanck smear is a dermatologic test in which scrapings are taken from the base of an ulcer and is used in the diagnosis of what 3 infections?

Answer 141

1. Herpes simplex
2. Varicella
3. Cytomegalovirus

Multinucleated giant cells on Tzanck smear are characteristic of Herpes and Varicella.

Question 142

Systemic corticosteroids are administered for preterm labor at what gestational age range?

Answer 142

24-34 weeks

Tocolysis should then be attempted with the goal being to maintain the pregnancy for at least 48 hours in order to realize the maximum benefit from the steroids.

Question 143

What is the most significant risk factor for distal limb reduction defects associated with chorionic villus sampling (CVS)?

Answer 143

Gestational age of the fetus

CVS before 10 weeks gestational age is associated with greater risk.

Question 144

Congenital anomalies, congenital infections, and chromosomal abnormalities usually result in what kind of intrauterine growth restriction (IUGR)?

Answer 144

Symmetric IUGR

In symmetric IUGR, the insult to the fetus often begins before 28 weeks gestation, and growth of both the head and the body are similarly lagging behind dates.

Question 145

What is the most common cause of decreased fertility in women in their fourth decade who are still experiencing menstrual cycles is what?

Answer 145

Age-related decreased ovarian reserve

Question 146

Gestational diabetes is most commonly treated with what?

Answer 146

First a low sugar diet, but if diet fails to produce euglycemia, insulin is the treatment of choice

Question 147

When is Trimethoprim-Sulfamethoxazole (TMP-SMX) permissible during pregnancy?

Answer 147

2nd trimester

Question 148

Secondary amenorrhea is relatively common in elite female athletes and results from what?

Answer 148

Estrogen deficiency

Amenorrhea is thought to occur in female athletes when there is a relative caloric deficiency secondary to inadequate nutritional intake as compared to the amount of energy expended.

Question 149

In what phase of the menstrual cycle is the cervical mucus thick, scant, and acidic, and will not allow penetration by spermatozoa?

Answer 149

The early follicular phase immediately following menstruation

Question 150

What must be avoided by any patient being treated for bacterial vaginosis or trichomonal vaginitis?

Answer 150

Alcohol

Patients who take metronidazole should abstain from drinking alcohol, as it is associated with a disulfiram-like reaction.

Question 151

What is the most appropriate treatment of chorioamnionitis associated with premature rupture of membranes?

Answer 151

Systemic broad-spectrum antibiotic therapy and expedited delivery of the fetus

Question 152

What presents similarly to mastitis but with a palpable, fluctuant mass?

Answer 152

Breast abscess

Treatment is drainage and antibiotics

Question 153

What is the most common cause of abnormal uterine bleeding?

Answer 153

Dysfunctional Uterine Bleeding (DUB)

This refers to heavy vaginal bleeding that occurs in the absence of structural or organic disease. It is most often the result of anovulation.

Question 154

What two diagnoses are possible in a pregnant patient with increased blood pressure prior to 20-weeks gestation?

Answer 154

1. Chronic hypertension
2. Hydatidiform mole

Question 155

What are the most appropriate first steps in the management of variable decelerations?

Answer 155

Oxygen administration and change in maternal position

Question 156

What is the most common cause of an abnormal maternal serum alpha-fetoprotein (MSAFP) level?

Answer 156

Gestational age error

Question 157

Maternal obstetrical trauma, past gynecological procedures (LEEP or cone bipsy), DES exposure, multiple gestation, and prior history of a preterm birth or a second trimester pregnancy loss are all risk factors for what?

Answer 157

Maternal cervical insufficiency

Question 158

Sudden onset of abdominal pain, fetal heart rate abnormalities, and recession of the presenting part during active labor indicate what probable diagnosis?

Answer 158

Uterine rupture

Risk factors include a pre-existing uterine scar or abdominal trauma.

Question 159

Patients with 47 XXY have what diagnosis?

Answer 159

Klinefelter’s syndrome

This is associated with male phenotype and small testes.

Question 160

What is the most common cause of mucopurulent cervicitis?

Answer 160

Chlamydia trachomatis

Question 161

Diabetic neuropathy causes what kind of incontinence?

Answer 161

Overflow incontinence

Question 162

What is the USPSTF recommendation on screening for Chlamydia and Gonorrhea in pregnant women?

Answer 162

Only screen women age 24 and younger, and those at increased risk

Increased risk includes a history of sexually transmitted infections, and new or multiple partners.

Question 163

What is the most appropriate test to confirm the diagnosis of intrauterine fetal demise (IUFD)?

Answer 163

Real-time ultrasonography

To demonstrate an absence of fetal movement and cardiac activity.

Question 164

Small genital warts (lesions) can be treated with what?

Answer 164

Trichloracetic acid or podophyllin

Question 165

The presence of dysmenorrhea, heavy menses, and an enlarged uterus is classic for what?

Answer 165

Uterine fibroids

Question 166

The risk of fetal polycythemia is increased in what gestational disorder?

Answer 166

Gestational diabetes

Polycythemia in an infant of a diabetic mother is the result of fetal hypoxia that occurs in the face of the increased basal metabolic rate induced by hyperglycemia. Increased erythropoietin production by the fetus increases the red blood cell mass and oxygen carrying capacity of the blood.

Question 167

What should be ruled out in pregnant patients with severe vomiting?

Answer 167

Gestational trophoblastic disease

Measurement of quantitative beta-hCG should be checked first. If the beta-hCG is markedly elevated, an ultrasonogram is then performed.

Question 168

What is the test of choice for diagnosis of ectopic pregnancy at beta-hCG levels of 1,500-6,500 IU/L?

Answer 168

Transvaginal ultrasound

Transvaginal ultrasound can demonstrate an intrauterine gestational sac when the beta-hCG is as low as 1500 IU/L (sometimes even at 800 IU/L). If transvaginal ultrasound reveals an intrauterine sac in the setting of a positive beta-hCG, then ectopic pregnancy is virtually ruled out. If transvaginal ultrasound reveals an adnexal sac and no intrauterine sac in this setting, then ectopic pregnancy is confirmed.

Question 169

What is on the differential diagnosis of a patient who is 46 XY but has a female phenotype?

Answer 169

1. Androgen insensitivity
2. 5-alpha-reductase deficiency

Question 170

It is recommended that, regardless of risk factors, all pregnant women be screened for what?

Answer 170

Syphilis

Screening should be performed at the first prenatal visit and is typically accomplished via the rapid plasma reagin (RPR) or venereal disease research laboratory (VDRL) test. When the screening test is positive, the diagnosis can be confirmed with the fluorescent treponemal antibody absorption (FTA-ABS) test.

Question 171

What is the most important complication of preterm premature rupture of membranes (PPROM)?

Answer 171

Pulmonary hypoplasia (immaturity)

Question 172

What happens to serum BUN and creatinine during pregnancy?

Answer 172

They are usually decreased

This is due to an increase in renal plasma flow and glomerular filtration rate.

Question 173

What is the treatment of choice for premenopausal women with simple or complex endometrial hyperplasia without atypia?

Answer 173

Cyclic progestins

All patients should undergo repeat biopsy after 3-6 months of treatment. The risk of progression to endometrial cancer in patients with simple or complex hyperplasia without atypia is low (1% and 3% respectively).

Question 174

In cases of aneuploidy, the maternal quadruple screen will return with what results?

Answer 174

1. Beta-hCG: Increased
2. MSAFP: Decreased
3. Estriol: Decreased
4. Inhibin A: Increased

Question 175

Painful 3rd trimester bleeding with normal ultrasound is most likely due to what?

Answer 175

Placental abruption

The role of ultrasound in the evaluation of antepartum hemorrhage is primarily to rule out placenta previa and not to diagnose placental abruption.

Question 176

This is a rare psychiatric condition in which a woman presents with nearly all signs and symptoms of pregnancy (amenorrhea, enlargement of the breasts and abdomen, morning sickness, weight gain, sensation of fetal movement, and positive urine pregnancy test per patient); however, ultrasound reveals a normal enometrial stripe and negative pregnancy test.

Answer 176

Pseudocyesis

Pseudocyesis is usually seen in women who have a strong desire to become pregnant. This is a form of conversion disorder, and management requires psychiatric evaluation and treatment.

Question 177

When is internal podalic version indicated?

Answer 177

During twin delivery to convert the second twin from a transverse or oblique presentation to a breech presentation for subsequent delivery

Question 178

What are the first-line agents for management of essential hypertension during pregnancy?

Answer 178

Labetalol and Methyldopa

Question 179

What is the most effective parameter for estimation of fetal weight in cases of suspected fetal growth restriction (FGR)?

Answer 179

Abdominal circumference

Question 180

1. In which tissues is Raloxifene an estrogen receptor agonist?
2. In which tissues is Raloxifene an estrogen receptor antagonist?

Answer 180

1. Agonist in bone tissue
2. Antagonist in breast and vaginal tissue

These characteristics make it a first-line agent for the prevention of osteoporosis, and it decreases breast cancer risk. It does, however, increase the risk of thromboembolism.

Question 181

What are the 2 most appropriate agents to treat hypertensive emergencies in pregnancy?

Answer 181

Intravenous hydralazine and labetalol

Methyldopa has a long history of safety in pregnancy but is not used to treat hypertensive emergencies due to its slow onset and sedative side effect at high doses.