OBGYN

Question 1

A 32 yo F presents to her PCP complaining of painful periods, pain with sex, and painful bowel movements. She has been trying to have kids since she got married 2 years ago. A pelvic exam reveals a 6 cm tender mass in the rectouterine pouch (RUP) along with nodularity of the uterosacral ligaments.

Answer 1

This is endometriosis (deposition of endometrial tissue outside the uterus). There are many theories as to why this occurs but “retrograde menstruation” is a commonly peddled one. Consider this as your dx with mention of the 3D’s->dyschezia, dysmenorrhea, and dyspareunia. The most common location is the ovary (where it can bleed and cause an endometrioma) followed by the RUP. Definitive dx is with laparoscopy. Tx options include combined/progestin OCPs (nuke HPG axis), continuous GnRH (not pulsatile), and surgery if fertility is desired (or TAHBSO if postmenopausal and reproduction is no longer required).

Question 2

Endometriosis is the most likely cause of ——— in a ——— woman over the age of ———, without a history of ———

Answer 2

infertility

menstruating

30

pelvic inflammatory disease.

Question 3

A 37-year-old patient reports hemoptysis during her period.

Answer 3

Endometriosis of the nasopharynx or lung.

Question 4

In endometriosis, severity of symptoms does not necessarily correlate with ———, but may correlate with the ———

Answer 4

quantity of ectopic endometrial tissue

depth of penetration of the ectopic tissue

Question 5

Long-term complications of endometriosis:
Prolonged bleeding of ectopic tissue causes ———, may contribute to: (4)

Answer 5

scarring (adhesions).

infertility, small bowel obstruction, pelvic pain, and difficult surgeries.

Question 6

Congenital anomalies that promote ——— may be found in adolescents with endometriosis.

Answer 6

retrograde menstruation

Question 7

Chronic pelvic pain may result from endometriosis with associated

Answer 7

adhesive disease

Question 8

Classic symptoms of endometriosis:

Answer 8

Dysmenorrhea, dyspareunia, and dyschezia

Question 9

———- has been shown to reduce endometriosis-related dysmenorrhea.

Answer 9

Acupuncture

Question 10

The pulsatile release of endogenous GnRH ——— FSH secretion. GnRH agonists cause ———- of pituitary receptors and ——— FSH secretion. This creates a ——— state.

Answer 10

stimulates

down regulation

suppress

pseudomenopause

Question 11

The only way to definitively diagnose adenomyosis is with

Answer 11

microscopic examination of the uterus after hysterectomy.

Question 12

When an enlarged uterus is found on exam, ultrasound can help differentiate between ——— and ———

Answer 12

adenomyosis and uterine fibroids.

Question 13

The diagnosis of adenomyosis
is suggested by characteristic
clinical findings; ———-(3) after ——— and ——— have been ruled out)

Answer 13

heavy menses, dysmenorrhea, enlarged uterus

endometriosis

leiomyomas

Question 14

Adenomyosis is classically described as an ——— uterus on physical exam.

Answer 14

enlarged, globular, “boggy”

Question 15

Adenomyosis vs Endometriosis: Cyclic-ness of pain

Answer 15

Adenomyosis: Noncyclic pain
Endometriosis: Cyclic pain

Question 16

Adenomyosis vs Endometriosis: Age and parity of women

Answer 16

Adenomyosis: Typically found in older, multiparous women
Endometriosis: Typically found in young, nulliparous women

Question 17

Adenomyosis vs Endometriosis: Responsive to hormonal stimulation.

Answer 17

Adenomyosis: Tissue is not as responsive to hormonal stimulation

Endometriosis: Tissue is responsive to hormonal stimulation.

Question 18

Oligomenorrhea is fewer than ——— menstrual cycles per year or cycle length of ——— days or more

Answer 18

nine

35

Question 19

Primary amenorrhea:

Answer 19

Absence of menses by age 15 with normal growth and secondary sexual characteristics
or
absence of menses by age 13 with no secondary sexual characteristics

Question 20

Secondary amenorrhea:

Answer 20

Absence of menses for ≥3 months in a woman who previously had a regular menstrual cycle
or
>6 months in a woman who had irregular menses

Question 21

A 32-year-old G0P0 patient presents with a 3-year history of infertility. She
experienced menarche at age 13, and has regular menses every 28 days. She reports severe pain 2–3 days before her period, pain during her period, and pain with intercourse. She reports no history of sexually transmitted infections (STIs). Her husband has one child from a previous marriage. On exam, she has uterosacral nodularity and a fixed, retroflexed uterus. How should the suspected diagnosis be confirmed? What findings would be present on a tissue biopsy?

Answer 21

The patient has classic symptoms of endometriosis: dysmenorrhea and dyspareunia. Endometriosis is often associated with infertility. Although history and exam may suggest endometriosis, diagnostic laparoscopy is required to make a definitive diagnosis. The tissue biopsy would show endometrial glands, stroma, and hemosiderin-laden macrophages. The most common sites of involvement are the ovaries and pouch of Douglas.

Question 22

A 39-year-old G4P4 patient presents with worsening heavy menstrual bleeding (HMB) and dysmenorrhea. On physical exam, the uterus is 14 weeks’ size, globular, boggy, slightly tender, and mobile. What is the next best step in management?

Answer 22

There is no proven medical therapy for adenomyosis, and hysterectomy is the only guaranteed treatment. However, conservative management with hormonal therapy is a reasonable next step. NSAIDs and OCPs can improve dysmenorrhea and regulate the heavy menses.

Question 23

A 40 yo F complains of increasing pain with menses for the past 11 months. Her periods are extremely heavy. Her last child was delivered 12 years ago with a subsequent tubal ligation. On pelvic exam, her uterus appears enlarged and tender with a globular, soft consistency.

Answer 23

This patient has adenomyosis (the deposition of endometrial glands in the myometrium). In contrast with a leiomyoma that has an asymmetric, firm, and nontender uterine presentation, adenomyosis has a symmetric, soft, and tender uterine presentation. Dx is usually clinical although an MRI may be helpful. It is very HY to know that dx can only be made conclusively by the examination of tissue after surgery. Tx is usually with the levonorgestrel IUD which may curb the menstrual bleeding. Definitive treatment revolves around getting a hysterectomy.

Question 24

When evaluating a patient with primary amenorrhea, note presence/absence of

Answer 24

breasts and uterus

Question 25

Primary amenorrhea + elevated serum FSH =

Answer 25

Gonadal dysgenesis. Most common cause of primary amenorrhea ~40–45%.

Question 26

17α hydroxylase deficiency: 46,XX: Breast ———, uterus ———; 46,XY: Breast ———, uterus ———

Answer 26

46,XX: Breast absent, uterus present 46,XY: Breast absent, uterus absent

Question 27

Androgen insensitivity:

Answer 27

Patients look female externally. No pubic hair. Remove gonads after puberty to avoid risk of malignancy (gonadoblastoma or dysgerminoma).

Question 28

An 18-year-old G0 patient presents with primary amenorrhea. Her sister experienced menarche at age 12. She reports no use of drugs, heavy exercise, or significant weight loss. She is 5′5′′ and 130 lb. Her blood pressure is 110/60. Physical exam demonstrates Tanner stage IV breasts, no axillary or pubic hair, and a blind vaginal pouch. What is the most likely diagnosis?

Answer 28

Answer: Androgen insensitivity. Breasts are present; uterus and axillary/pubic hair is absent in androgen insensitivity.

Question 29

What is the result of Müllerian agenesis?

Answer 29

Absent uterus

Question 30

Second most common cause of primary amenorrhea

Answer 30

Müllerian agenesis

Question 31

Normal breast and pubic hair + no menses + cyclic pelvic pain + bulging blue mass at the introitus =

Answer 31

Hematocolpos from imperforate hymen

Question 32

Androgen Insensitivity vs Müllerian Agenesis: Karyotype

Answer 32

Androgen Insensitivity: XY Müllerian Agenesis: XX

Question 33

Androgen Insensitivity vs Müllerian Agenesis: Breast

Answer 33

Androgen Insensitivity: Present Müllerian Agenesis: Present

Question 34

Androgen Insensitivity vs Müllerian Agenesis: Uterus

Answer 34

Androgen Insensitivity: Absent Müllerian Agenesis: Absent

Question 35

Androgen Insensitivity vs Müllerian Agenesis: Pubic/axillary hair

Answer 35

Androgen Insensitivity: Absent Müllerian Agenesis: Normal

Question 36

Androgen Insensitivity vs Müllerian Agenesis: Testosterone

Answer 36

Androgen Insensitivity: Normal male levels Müllerian Agenesis: Female levels

Question 37

Androgen Insensitivity vs Müllerian Agenesis: Further evaluation

Answer 37

Androgen Insensitivity: Need gonadectomy Müllerian Agenesis: Renal/skeletal abnormalities

Question 38

The most common cause of secondary amenorrhea is

Answer 38

pregnancy. Always check a pregnancy test in a reproductive-age woman.

Question 39

A 30-year-old G2P2002 patient, with last menstrual period (LMP) 8 weeks ago, presents with no menses for 2 months. She usually has menses every 28 days lasting for 5 days. She reports no medical or surgical history. She has had two vaginal deliveries at term. She uses combination oral contraceptive pills (OCPs), and has not missed any pills recently. What is the next step in management of this patient?

Answer 39

The most common cause of amenorrhea in a reproductive-age woman is pregnancy, so a urine or serum β-hCG should be checked. Contraception use does not prevent pregnancy 100% of the time.

Question 40

Adolescent girls with amenorrhea should be screened for

Answer 40

disordered eating patterns

Question 41

What is Sheehan syndrome?

Answer 41

Postpartum pituitary dysfunction due to intrapartum ischemia

Question 42

In Sheehan syndrome, patients do not produce ——— due to ———

Answer 42

milk the absence of prolactin

Question 43

Sheehan syndrome typically presents with —(2)— after delivery in a patient with a history of ———

Answer 43

failure of postpartum lactation and failure to resume menses severe postpartum hemorrhage

Question 44

Sheehan syndrome: ——— occurs due to severe ——— resulting in hypotension and often requiring blood transfusion. Treatment includes ———

Answer 44

Pituitary cell infarction post-partum hemorrhage replacement of pituitary hormones

Question 45

Primary ovarian insufficiency: 3 key elements presentation

Answer 45

■ Age <40 ■ Amenorrhea ■ Elevated FSH

Question 46

A 35-year-old G2P2002 patient with LMP 1 year ago presents with hot flashes and vaginal dryness. Her serum FSH is very high. What is the most likely diagnosis?

Answer 46

Primary ovarian insufficiency. Symptoms are similar to those in menopause and diagnosis is confirmed with elevated FSH

Question 47

Patients who exercise or play sports intensely may develop the “female athlete triad,” characterized by

Answer 47

amenorrhea, disordered eating, and decreased bone mineral density. The primary issue is energy imbalance, whereby more calories are expended than consumed.

Question 48

——— is the most common cause of hirsutism.

Answer 48

PCOS

Question 49

A 35-year-old G3P3003 patient presents with absence of menses for 8 months. She reports menarche at age 12 with menses every 40–50 days until recently. She reports a 20-lb weight gain over the last year. She used letrozole to become pregnant with her last two pregnancies. Vitals show height 5′4′′, weight 220 lb, BP 120/80. She has hair on her upper lip and chin, acne, and oily skin on her face. What is the most likely diagnosis? If left untreated, what is this patient at ↑ risk for?

Answer 49

Polycystic ovarian syndrome (PCOS). Diagnosis of PCOS is established with two out of three of the following: a history of oligomenorrhea/amenorrhea, features of hyperandrogenism (acne, hirsutism), and multiple ovarian cysts seen on ultrasound. This patient is at ↑ risk for endometrial hyperplasia or cancer if left untreated.

Question 50

A 28-year-old G0 patient has been unable to conceive with her husband over 1 year of regular, unprotected intercourse. Her periods are irregular. She has a BMI of 30, displays coarse facial hair, and a dark velvety pigmentation on the back of her neck. What is the likely diagnosis in this patient? What is the most likely reason she is unable to conceive?

Answer 50

Polycystic ovarian syndrome (PCOS) affects approximately 5% of all women, and is a leading cause of infertility. Her exam shows evidence of hyperandrogenism and insulin resistance. She is anovulatory and will likely need an ovulation induction agent to conceive.

Question 51

Treatment of choice for PCOS:

Answer 51

Combined OCPs as they manage hyperandrogenism, menstrual irregularities, and provide contraception.

Question 52

Asherman syndrome: Intrauterine adhesions can

Answer 52

obliterate the endometrial cavity and cause amenorrhea.

Question 53

Asherman syndrome is ——— secondary to ———

Answer 53

intrauterine adhesions uterine curettage associated with pregnancy (including after SAB, for retained placenta, or PPH) or shortly thereafter with resultant scarring.

Question 54

The most common symptoms associated with Asherman syndrome include (4)

Answer 54

amenorrhea or light periods, infertility, cyclic pelvic pain, recurrent pregnancy loss.

Question 55

Progestin challenge test:

Answer 55

Give oral progestin for 10 days. If the endometrium has been primed with estrogen from ovaries or peripheral fat, the withdrawal of progestin after 10 days will cause endometrial sloughing with resultant withdrawal bleed. No withdrawal bleeding indicates absence of ovaries, estrogen deficiency, or outflow obstruction.

Question 56

Consider Asherman syndrome as the dx if a woman has ——— and the Q stem gives you a history of (2)

Answer 56

amenorrhea dilation and curettage or super bad PID (In some cases, these “uterine disturbances” create scar tissue that can cause amenorrhea/infertility)

Question 57

Asherman syndrome treatment

Answer 57

Hysteroscopic lysis of these adhesions + estrogen typically is a good management step.

Question 58

Do not forget to order a ——— in a woman presenting with amenorrhea

Answer 58

serum B-HCG (In addition, consider taking a look at the TSH, prolactin levels (give Cabergoline as tx), androgen levels (testosterone and DHEAS), etc. )

Question 59

A woman with PCOS will have a ———progesterone withdrawal challenge

Answer 59

+ve

Question 60

A woman with Asherman’s syndrome/some kind of obstructive lesion in the uterus/cervix will have a ———progesterone withdrawal challenge.

Answer 60

-ve (This will also be the case with someone having low E2 levels.)

Question 61

The Tanner stages of development refer to the ———; these are———

Answer 61

sequence of events of breast and pubic hair development. Stage 1: Prepuberty Stages 2–4: Development stages Stage 5: Adult development

Question 62

The first menstrual bleeding is usually caused by the effects of——— stimulating the ———, rather than by ovulation.

Answer 62

estradiol endometrial lining

Question 63

Puberty is believed to begin with ———

Answer 63

disinhibition of the pulsatile GnRH secretion from the hypothalamus

Question 64

GnRH stimulates the

Answer 64

anterior pituitary gland to secrete follicle-stimulating hormone (FSH) and luteinizing hormone (LH)

Question 65

At puberty in girls, FSH stimulates ———, and along with LH, stimulates production of ——— (which causes (3))

Answer 65

growth of ovarian follicles estradiol in the ovaries breast development, skeletal growth, and stimulation of the endometrium (Later, FSH and LH lead to ovulation and menstruation)

Question 66

Thelarche is ———; average age ———; dominant hormone ———

Answer 66

breast budding 10 estradiol

Question 67

Pubarche is ———; average age ———; dominant hormone ———

Answer 67

axillary and pubic hair growth 11 Adrenal hormones (androgens)

Question 68

Menarche is ———; average age ———; dominant hormone ———

Answer 68

first menses 12 Estradiol

Question 69

A female age ——— or older without any breast development should be evaluated for delayed puberty.

Answer 69

13

Question 70

Menstrual cycle is from he HPO axis and uterus interacting to allow ovulation approximately ——— [average ——— days (+/– ———days)].

Answer 70

once per month 28 7

Question 71

In menstruation, many follicles are stimulated by ———, but the follicle that ——— will be released

Answer 71

FSH secretes more estrogen than androgen

Question 72

In menstruation, the dominant follicle ——— so that its positive feedback causes an ———

Answer 72

releases the most estradiol LH surge

Question 73

Menstruation: Withdrawal of ——— causes ———

Answer 73

progesterone endometrial sloughing

Question 74

■ Average duration of menses = ■ Normal menstrual cycle length =

Answer 74

5 days 21–35 days

Question 75

——— released from the ——— cause dysmenorrhea.

Answer 75

Prostaglandins endometrium

Question 76

Before ovulation vs after ovulation: ovarian phase

Answer 76

Before ovulation: follicular After ovulation: luteal

Question 77

Before ovulation vs after ovulation: uterine phase

Answer 77

Before ovulation: proliferative After ovulation: secretory

Question 78

Before ovulation vs after ovulation: dominant hormone

Answer 78

Before ovulation: estrogen After ovulation: progesterone

Question 79

Follicular phase: FSH causes (2)

Answer 79

follicle maturation and estrogen secretion

Question 80

Follicular phase (day 1-14): Estrogen causes

Answer 80

endometrial proliferation

Question 81

Ovulation (Day 14): The LH surge causes the ———. The ruptured follicle then becomes the ———, which secretes ———.

Answer 81

oocyte to be released from the follicle corpus luteum progesterone

Question 82

Luteal phase (14-28): Corpus luteum secretes ———, which causes (2)

Answer 82

progesterone Endometrial maturation and↓FSH,↓LH

Question 83

Ovulation takes place ——— hours after LH surge and ——— hours after LH peak.

Answer 83

24–36 12

Question 84

The length of the ——— phase is highly variable. The ——— phase is usually about 14 days due to the ———. Individuals who have changes in their cycle length typically experience changes in the ——— phase.

Answer 84

follicular luteal length of time the corpus luteum is able to secrete progesterone follicular

Question 85

The corpus luteum is maintained after fertilization by ———, which is released by ———.

Answer 85

hCG embryo

Question 86

After progestin challenge test, give ——— to Distinguish Between Hypoestrogenism or an Outflow Tract Obstruction (Asherman’s Syndrome or Cervical Stenosis): If bleeding occurs, amenorrhea is due to ——— If bleeding does not occur, then most likely it is ———

Answer 86

Estrogen and Progestin (Give estrogen to ensure endometrial proliferation, followed by a progestin to induce withdrawal bleeding. ) hypoestrogenism (hypothalamic amenorrhea or premature ovarian failure) outflow tract obstruction – either Asherman’s syndrome or cervical stenosis.

Question 87

“bluish bulge” in the vagina associated with ———; treated with ———

Answer 87

an imperforate hymen “cruciate incision”

Question 88

23 yo F has had menses before, missed her last 3 periods, urine B-HCG is +ve

Answer 88

she’s pregnant

Question 89

23 yo F has had menses before, missed her last 3 periods, biopsy reveals lymphoid follicles in the thyroid

Answer 89

Hashimoto’s, high TRH, hyperprolactinemia

Question 90

23 yo F has had menses before, missed her last 3 periods, has galactorrhea

Answer 90

prolactinoma (tx with bromocriptine, cabergoline)

Question 91

23 yo F has had menses before, missed her last 3 periods, was diagnosed with schizophrenia 3 mo ago

Answer 91

dopamine antagonists, hyperprolactinemia.

Question 92

35 yo F has had menses before, BMI of 32, irregular menses for the past 5 years

Answer 92

PCOS

Question 93

Gestational age:

Answer 93

The time of pregnancy counting from the first day of the last menstrual period (LMP).

Question 94

First trimester: Second trimester: Third trimester:

Answer 94

First trimester: 0–12 weeks. Second trimester: 13–27 weeks. Third trimester: 28 weeks–birth.

Question 95

Embryo: Fetus:

Answer 95

Embryo: Fertilization–8 weeks. Fetus: 9 weeks–birth.

Question 96

Previable: Periviable: Preterm: Term:

Answer 96

Previable: <22 weeks. Periviable: 22–24 weeks. Preterm: 20–36 weeks. Term: 37–42 weeks.

Question 97

Remember that ——— has the highest correlation with congenital abnormalities.

Answer 97

alcohol use

Question 98

20 yo F has breasts and a uterus, levels of all hormones are normal

Answer 98

imperforate hymen, or anything weird that blocks the vagina. She is actually menstruating, but the blood is not making its way out. Dx is by PE, tx is with surgery.

Question 99

20 yo F supermodel (or hardcore athlete) has breasts and a uterus (what should be true of her hormone levels?)

Answer 99

this is either anorexia nervosa/just working out too much. In the setting of severe physiologic stress, the GnRH axis is turned off. Therefore, GnRH/LH/FSH/Estrogen levels are all low.

Question 100

20 yo F has breasts and no uterus, testosterone levels are super high

Answer 100

she has no uterus b/c she is 46 XY. this is testicular feminization syndrome (or Androgen Insensitivity Syndrome)- Sertoli cells make MIH so the mullerian duct is nuked (oviducts, uterus, upper third of the vagina). She has breasts b/c the testosterone is aromatized to estrogen in the periphery. Why should she have an orchiectomy after puberty?

Question 101

20 yo F has breasts and no uterus, karyotype reveals a 46 XX phenotype

Answer 101

Mullerian Agenesis (Mayer Rokitansky Kuster Hauser Syndrome). For whatever reason, the mullerian duct does not develop so there’s no uterus. She has ovaries which produce estrogen (ovaries are not derived from the mullerian ducts) so she has breasts. Whenever you see breasts, estrogens are around. Whenever you see pubic hair, androgens are around.

Question 102

20 yo F has no breasts, but has a uterus, she can’t smell

Answer 102

Kallmann Syndrome, everything will be low-GnRH down. No breasts b/c the ovaries are making no estrogen. Give pulsatile leuprolide.

Question 103

20 yo F is 3’ 5” tall, low posterior hairline, widely spaced nipples, BP of 150/120 in the arms and a BP of 65/40 in the legs, has a uterus, no breasts

Answer 103

this is Turner’s syndrome. Turner’s is a kind of hypergonadotropic hypogonadism (streak ovaries) so the FSH levels will be high. Karyotype is 45 XO. Common associations include bicuspid aortic valves, coarctation of the aorta (BP differences b/w the arms and legs), horseshoe kidney, amongst other anomalies. With the ovaries basically non-existent, there is no estrogen (or very little), so there is no breast development.

Question 104

20 yo F with a uterus, no breasts, and visual field deficits

Answer 104

some kind of brain tumor (like a craniopharyngioma, considering the VF deficits). A compressive lesion of the anterior pituitary may hamper LH/FSH production so the ovaries are not stimulated (so there’s no estrogen = no breasts).

Question 105

A 31-year-old G2P1001 patient at 17 weeks’ gestation undergoes routine prenatal tests. Her results show that her blood type is A negative, and her antibody screen is positive. She does not report undergoing a blood transfusion in the past or any complications with her last pregnancy. What is the next step in the management of this patient?

Answer 105

The next step is to identify the antibody. There are many types of antibodies, and in a patient that is Rh negative, it should not be assumed that she has Rh antibodies.

Question 106

The only contraceptive methods that protect against STIs are

Answer 106

the male and female condoms

Question 107

——— accounts for most condom failures.

Answer 107

Inconsistent condom use

Question 108

If diaphragm left in for too long (>24 hours), in rare cases, may result in

Answer 108

Staphylococcus aureus infection (which may cause toxic shock syndrome).

Question 109

Efficacy rates for spermicides are much higher when

Answer 109

combined with other barriers (i.e., condoms, diaphragms).

Question 110

A 37-year-old G2P2 patient desires a reversible form of contraception. Her history is significant for migraines with visual aura, uncontrolled hypertension (HTN), and family history of breast cancer in her mother. She smokes two packs of cigarettes daily. She requests combination oral contraceptives (COCs). How should this patient be counseled?

Answer 110

The patient is not a candidate for COCs because she has several contra- indications that put her at an increased risk for developing venous thromboembolism and stroke. Contraindications for COC use include age >35 years old and smoking, history of venous thromboembolism, uncontrolled HTN, diabetes with vascular disease, migraines with visual aura, and benign or malignant liver tumors, cirrhosis, and personal history of breast cancer.

Question 111

——— headaches are not a contraindication for COCs. ——— headaches can increase risk of stroke in patients who take combination hormonal contraception.

Answer 111

Tension Migraine with visual aura

Question 112

P450 inducers will decrease the efficacy of ——— contraceptives (e.g., phenytoin, rifampin, griseofulvin, carbamazepine, barbiturates) due to accelerated metabolism of ———.

Answer 112

oral OCPs

Question 113

Hormonal patch may be less effective in

Answer 113

obese (≥200 lb) women.

Question 114

Types of endogenous estrogens: Reproductive life: ——— Pregnancy: ——— Menopause: ———

Answer 114

Estradiol Estriol Estrone (Estrone (E1): People make this type of estrogen after menopause. Estradiol (E2): This is the most common type of estrogen that people make. Estriol (E3): This is the main type of estrogen in a pregnant person’s bloodstream.)

Question 115

The inactive pills in the COC simulate ———, which results in menses.

Answer 115

hormone withdrawal of the normal menstrual cycle

Question 116

Always check a β-hCG to rule out pregnancy before prescribing the acne medicine ——— (very teratogenic!).

Answer 116

isotretinoin

Question 117

What is the treatment for idiopathic hirsutism?

Answer 117

OCPs

Question 118

Oral contraception mechanism in a nutshell: ■ Estrogen inhibits ——— ■ Progestin inhibits ———

Answer 118

FSH (prevents follicular development) LH (inhibits ovulation)

Question 119

COC: Estrogen and progesterone combined. Main mechanisms: (4)

Answer 119

■ Prevents ovulation ■ Alters uterine and fallopian tube motility ■ Thickens cervical mucus to prevent sperm penetration ■ Causes endometrial atrophy

Question 120

There is no proven link between OCP use and ↑ in

Answer 120

breast cancer

Question 121

Estrogen can impact ———, so combination pills are not recommended for ———. ——— are recommended until that time.

Answer 121

breast milk supply and production nursing mothers until milk supply is stable Progestin-only pills

Question 122

Side effects of estrogen: (3)

Answer 122

■ Breast tenderness ■ Nausea ■ Headache

Question 123

Side effects of progestin: (4)

Answer 123

■ Depression ■ Acne ■ Weight gain ■ Irregular bleeding

Question 124

Why is estrogen a procoagulant?

Answer 124

Estrogen ↑ factors VII and X and ↓ antithrombin III.

Question 125

A 20-year-old G0 patient desires long-acting reversible contraception. She has a history of epilepsy for which she takes an anticonvulsant. She still has seizures once about every 6 months. She is also wary of anything that goes ‘in her body’. What is the best contraceptive method for her?

Answer 125

Medroxyprogesterone acetate (DMPA) injection can ↑ the seizure threshold and ↓ the number of seizures. It also ↓ the number of sickle cell crises in patients with sickle cell disease. It improves anemia, ↓ dysmenorrhea and ovarian cysts, and improves symptoms of endometriosis.

Question 126

Most common complaint / reason for stopping Medroxyprogesterone acetate (DMPA) injection:

Answer 126

Weight gain

Question 127

Non-user-dependent methods like the IUD, subdermal implant, and injections have lower failure rates than ———.

Answer 127

OCPs

Question 128

IUDs and contraceptive implants, also called long-acting reversible contraceptives (LARC), are the most effective

Answer 128

reversible contraceptive methods

Question 129

If the IUD strings are not visible on follow-up speculum examination, a cytobrush can be used to ———. If this is not successful, then an ——— should be performed to determine the location of the IUD. If the IUD is not visible in the uterus on ———, then an ——— should be performed to assess for possible ———.

Answer 129

try to pull the strings down and out of the cervical os. ultrasound ultrasound abdominopelvic X-ray uterine perforation

Question 130

A 25-year-old G1P1patient, who delivered a full-term infant 6 months previously, presents for IUD insertion. She reports that she is in a long-term, monogamous relationship. She reports no history of STIs or other medical conditions. She undergoes the insertion of an IUD without any apparent complications. The patient presents 4 days later with abdominal pain, nausea, vomiting, and fever. Speculum exam reveals malodorous discharge and IUD strings at the cervical os. What is the most likely cause for the patient’s symptoms?

Answer 130

Endometritis due to contamination during insertion. Infections that occur near the time of IUD insertion are usually due to ascending infection from vaginal flora. Infections, months to years, after the IUD placement may be due to STIs.

Question 131

Contraindication for IUD placement: ———, due to ———

Answer 131

Severe distortion of uterine cavity (e.g., bicornuate uterus or large obstructive fibroids) increased difficulty with insertion, increased risk of IUD expulsion/ embedment/perforation, and decreased efficacy.

Question 132

The absolute risk of ——— is lower for women using an IUD compared with women not using contraception or using other reversible methods of contraception. However, should a pregnancy occur in a patient using and IUD, the risk of ——— is higher, ranging from 10 to 30%.

Answer 132

ectopic pregnancy ectopic pregnancy

Question 133

——— are the most effective method of emergency contraception (both types are more than 99% effective). Another benefit of this method is that they may be ———

Answer 133

IUDs left in place in order to continue to provide ongoing, highly effective contraception.

Question 134

The only contraceptive methods that protect against STDs are

Answer 134

abstinence/condoms.

Question 135

Combined OCPs work by (2)

Answer 135

inhibiting ovulation (E2 -ve feedback) ncreasing the thickness of cervical mucus (progesterone)

Question 136

Avoid combined OCPs in individuals with (7)

Answer 136

history of a DVT/PE Weird genetic diseases like Factor 5 Leiden history of cancers driven by E2 (like breast) people with bad HTN patients with hepatic adenomas smokers > 35 yo h/o migraine with aura/atypical migraine involving neuro deficits.

Question 137

Combined OCPs decrease the risk of

Answer 137

ovarian/endometrial cancer (fewer cycles)

Question 138

If a lady is being treated for TB and becomes pregnant with regular combined OCP use, think of

Answer 138

revved up metabolism from rifampin mediated CYP450 induction.

Question 139

Progestin only pills MOA involves thickening

Answer 139

cervical mucus

Question 140

Progestin only pills associated with (2)

Answer 140

weight gain reversible osteoporosis.

Question 141

Progestin only pills are good ——— options

Answer 141

postpartum

Question 142

A progesterone derivative (Megestrol) is given to

Answer 142

stimulate the appetite in cachectic patients

Question 143

The Cu IUD is an excellent contraceptive that works by causing

Answer 143

an inflammatory reaction that makes the uterus inhospitable for sperm and eggs

Question 144

Remember the association of ———with a history of tubal ligation.

Answer 144

ectopic pregnancies

Question 145

The Cu IUD is should be avoided in a woman with (2)

Answer 145

History of heavy menses Wilson’s disease

Question 146

A 22 yo G1P1 female visits her obstetrician 1 week after she delivered a boy that weighed 6 Lbs and 4 ounces. The delivery was unremarkable with APGAR scores of 8 and 9 at 1 and 5 minutes respectively. The patient plans to have her next baby when she graduates from graduate school 2 years from now. In addition to routine screening for postpartum depression, what is the next best step in the management of this patient? a. Discussion of the benefits of breastfeeding as an excellent long term form of birth control. b. Cervical swabs for N. Gonorrhoeae and C. Trachomatis. c. Prescription for a combined oral contraceptive pill. d. Prophylactic sertraline for postpartum depression. e. Obtaining consent for the administration of depo medroxyprogesterone acetate during this visit.

Answer 146

The best answer here is E. Progestin only contraceptives are the ideal option

Question 147

In the postpartum period, ——— may be ok as birth control for a 6 mo period, however it is not completely reliable.

Answer 147

breastfeeding

Question 148

In a woman that expresses a desire for birth control postpartum, resist the temptation to prescribe

Answer 148

anything containing estrogen (inhibits breastfeeding)

Question 149

Progestin only contraceptives MOA involves

Answer 149

thickening cervical mucus

Question 150

Progestin only contraceptives protect against

Answer 150

endometrial cancer

Question 151

Progestin only contraceptives avoided in the setting of

Answer 151

breast cancer (or other progesterone receptor positive gynecologic malignancies)

Question 152

Association of injectable progesterone with (3)

Answer 152

delayed return to fertility after discontinuation (up to a year) possible weight gain in some cases, a decrease in bone mineral density

Question 153

Treat breast mastitis with

Answer 153

dicloxacillin

Question 154

A 26-year-old patient who is 4-weeks postpartum presents with a 1-day history of fever of 100.9°F (38.3°C) and breast tenderness. She has been breast-feeding without problems and reports no other symptoms. Her left breast has a 4-cm area of induration and erythema at the 3 o’clock position that is tender to palpation. Milk expressed from that breast is white. What is the most likely diagnosis? What is the treatment?

Answer 154

Mastitis. Focal area of breast infection and fever approximately 1 month postpartum is consistent with mastitis. The patient should be started on dicloxacillin.

Question 155

Breast-Associated Fevers: Mastitis timeframe

Question 156

Breast-Associated Fevers: Mastitis timeframe

Question 157

Mastitis (Breast-Associated Fevers): timeframe

Answer 157

Anytime while lactating (usually >3–4 weeks postpartum)

Question 158

Mastitis (Breast-Associated Fevers): presentation

Answer 158

Focal erythema and induration, streaking on the breast

Question 159

Mastitis (Breast-Associated Fevers): causative agent

Answer 159

Staph aureas, MRSA, coag negative staph

Question 160

Mastitis (Breast-Associated Fevers): management

Answer 160

Treat with dicloxacillin for 7–10 days

Question 161

Mastitis (Breast-Associated Fevers): continue breastfeeding?

Answer 161

Yes

Question 162

Breastfeeding is associated with a decreased risk of (2)

Answer 162

Breast cancer (Prolactin shuts down GnRH which nukes estrogen production. Estrogen drives many breast cancers.) Ovarian cancer (Prolactin shuts down GnRH which causes anovulation. With anovulation, the ovarian epithelium does not have to be broken down and repaired each month (which happens with ovulation). This reduces the potential for malignant transformation of ovarian epithelium.)

Question 163

Breast feeding helps with

Answer 163

weight loss

Question 164

A woman with (3) should not breastfeed

Answer 164

HIV active TB active herpes lesions on the breast

Question 165

Infants with ——— is a contraindication to breastfeeding.

Answer 165

Galactosemia

Question 166

A 28-year-old woman, gravida 1, para 1, comes to the office to discuss a recent cervical pap smear. The cytology report says that she has atypical squamous cells of undetermined significance (ASCUS). She has never had an abnormal pap smear result before. Reflex human papillomavirus (HPV) testing is negative. Which of the following is the most appropriate next step in managing this patient? - Human papillomavirus vaccine - Repeat pap smear with HPV testing in 1 year - Repeat pap smear with HPV testing in 3 years - Colposcopy with biopsies - Loop electrosurgical excision procedure

Answer 166

Repeat pap smear with HPV testing in 3 years (Note: At which point 28yo pt will be over 30!) Co-testing, pap smear and human papillomavirus (HPV) testing, is an appropriate follow-up plan for young women with atypical squamous cells of undetermined significance (ASCUS). This should be performed 3 years after the abnormal cytology report. For the woman described in the question, a pap smear has identified atypical cells of undetermined significance (ASCUS). According to the American Society for Colposcopy and Cervical Pathology (ASCCP) as well as the American College of Obstetricians and Gynecologists (ACOG), the preferred next step is to do reflex human papillomavirus (HPV) testing. If HPV testing is negative, as in this patient, the next step is to repeat a pap smear with reflex HPV testing in 3 years (this is known as "co-testing"). However, if HPV testing is positive, colposcopy is warranted. For women age 30 or great, ASCUS doesn't even warrant HPV testing - current recommendations are just to do co-testing in 3 years. An acceptable alternative to reflex HPV testing is to repeat the pap test in one year, but HPV testing is more likely to grant immediate peace of mind, as well as reduce the number of procedures performed.

Question 167

A 30-year-old woman is brought to the emergency department because of altered mental status. Collateral history shows that the patient has been fatigued over the last 24 hours, and today did not recognize her husband. In addition, she has had a decreased appetite and vomiting over the past 12 hours. She is known to have cervical cancer for which she is awaiting treatment. Current medications include only oxycodone. Vitals signs show her temperature is 37°C (98.6°F), pulse is 85/min, respirations are 26/min, blood pressure is 160/90 mmHg, and oxygen saturation is 94% on room air. Physical examinations shows a drowsy, diaphoretic female, asterixis, and moderate distension inferior to the umbilicus. Initial laboratory results are shown below. Sodium: 135 mEq/L Potassium: 4.9 mEq/L Chloride: 99 mmol/L Bicarbonate: 12 mEq/L Blood Urea Nitrogen: 65 mg/dL (high) Creatinine: 3.5 mg/dL (high) Glucose: 122 mg/dL Hemoglobin: 14 g/dL Which of the following is the most likely cause of this patient’s altered mental status? - Medication overdose - Uremic encephalopathy - Brain metastasis - Hepatic encephalopathy - Severe sepsis

Answer 167

Uremic encephalopathy Complications of malignancy can present in a variety of ways, as shown in this case of cervical cancer. Obstructive uropathy can cause post-renal failure leading to uremia and uremic encephalopathy. The patient has confusion, decreased alertness, vomiting, and asterixis, all which are consistent with an encephalopathic condition. This patient has confusion, decreased alertness, vomiting, and asterixis, all of which are consistent with an encephalopathic condition. Note that the patient also has acute renal failure, with a BUN of 65 g/dL and a creatinine of 3.5 mg/dL, and an anion gap of 24. The most likely cause of these abnormalities is acute uremic encephalopathy. Uremia will cause an anion gap metabolic acidosis, which may explain why the patient is diaphoretic and tachypneic. One possible etiology of this patient's renal failure is obstructive uropathy from the underlying cervical cancer compressing the lower urinary outflow tract. The patient’s lower abdominal distension likely represents a distended bladder.

Question 168

HPV types associated with low- grade cervical lesions and 90% of anogenital warts

Answer 168

Types 6 and 11

Question 169

HPV types associated with >50% of high-grade cervical lesions and 70% of cervical cancer

Answer 169

HPV Types 16 and 18

Question 170

Vaccines against high-risk strains of HPV are currently FDA approved for

Answer 170

females and males between the ages of 9 and 45 years

Question 171

Risk Factors for Cervical Dysplasia and Cervical Cancer

Answer 171

■ HPV infection ■ ↑ sexual activity (↑ risk of viral/bacterial infections) ■ Low socioeconomic status (likely due to limited access to health care and screening) ■ Genetic predisposition ■ Cigarette smoking (increases risk for squamous cell cancers but not adenocarcinomas) ■ OCPs (condoms ↓ risk in these women) ■ Immunosuppression

Question 172

A 21-year-old G2P2 patient desires contraception. She has been sexually active for 4 years, with three lifetime partners. Her menses are irregular. Before prescribing combined OCPs, what tests need to be performed?

Answer 172

A pregnancy test, Pap test, and STI screening

Question 173

Define a Pap test

Answer 173

A Pap test is a cytologic screening test for cervical dysplasia

Question 174

The methods available for cervical cancer screening are

Answer 174

Pap test (i.e., cytology), HPV testing, and co-testing with both cytology and HPV

Question 175

The ectocervix is comprised of ——— epithelium, and the endocervix (including cervical canal) is comprised of ——— epithelium.

Answer 175

squamous glandular (columnar)

Question 176

Pap test is a screening test that provides ——— information, not ——— information

Answer 176

cytologic histologic

Question 177

Pap test screening should begin

Answer 177

not begin until age 21, regardless of sexual activity

Question 178

USPSTF recommendations on screening for cervical cancer

Answer 178

Screening in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and HPV testing every 5 years

Question 179

Pap smears are not helpful in women after

Answer 179

hysterectomy (for non-cancer disease)

Question 180

Contrast types of cervical cancer in terms of commonness and location:

Answer 180

Squamous cell cancer (outer cervix) is the most common kind of cervical cancer Adenocarcinomas can also occur but are typically in the inner cervix that is not necessarily visible with a speculum exam

Question 181

Most cervical cancers arise in the

Answer 181

transformation zone between the ecto and endocervix (Specifically, most cervical cancers arise at the squamocolumnar junction)

Question 182

RFs for cervical cancer:

Answer 182

The biggest RF is a history of exposure to HPV (especially 16 and 18). Other RFs include: having multiple sex partners, having a h/o of STDs, having HIV (immunosuppression), smoking

Question 183

You certainly need to know the screening guidelines for cervical cancer.

Answer 183

A woman should be screened every 3 years from 21-29. A similar regimen can be pursued after the age of 30. However, a pap smear + HPV screening can be conducted every 5 years. Screening can be stopped at 65 if multiple pap smears have been normal.

Question 184

Screening for cervical cancer no longer necessary if:

Answer 184

A patient that undergoes a hysterectomy FOR BENIGN REASONS does not need further screening after the procedure. For NON-BENIGN reasons, a pap smear of the vaginal cuff must be undertaken at routine intervals.

Question 185

A pap smear revealing ASCUS (atypical squamous cells of undetermined significance) should be followed by ——— if the patient is over 25. If HPV+, ———. If < 25, ———. If +ve, ———.

Answer 185

HPV testing proceed to a colposcopy an acceptable option is to repeat the pap in a year (but preferred from osmosis also HPV Testing) proceed to colposcopy Option 1 (for the > 25 yo F) is also acceptable.

Question 186

If a pap smear reveals ASC-H (ASC but cannot exclude HSIL; atypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion):

Answer 186

proceed to a colposcopy

Question 187

If a pap smear reveals AGUS (Atypical Glandular Cells of Undetermined Significance), your NBSIM is:

Answer 187

to get a whole bunch of tests: colposcopy, endocervical curettage, and an an endometrial biopsy

Question 188

If a pap smear reveals low-grade squamous intraepithelial lesions (LSIL or cervical intraepithelial neoplasia (CIN 1)), it is typically acceptable to ———. In some rare cases with super low risk individuals (aka really young), ———

Answer 188

get a colposcopy with biopsy the pap may be repeated in a year since these individuals will more than likely clear the infection

Question 189

High-grade squamous intraepithelial lesions (HSIL or CIN 2 or 3),———l

Answer 189

proceed to a colposcopy always An unusual answer you may see on the NBME is to perform a Loop Electrosurgical Excision Procedure (LEEP) procedure to excise the lesion

Question 190

If a pap smear shows LSIL (CIN 1) but a colposcopy with biopsy shows something different (e.g. HSIL with CIN 2⁄3):

Answer 190

repeat the colposcopy and get an endocervical curettage

Question 191

Consider cervical cancer if a Q stem gives you a patient with cervical cancer RFs in the setting of:

Answer 191

post-coital bleeding

Question 192

Cervical cancer can metastasize to ——— structures and cause ———

Answer 192

urinary system (like ureters) hydronephrosis leading to renal failure (When cervical cancer spreads to other areas of the pelvis, it can block one or both ureters, which carry urine from the kidneys to the bladder. This can lead to a condition called hydronephrosis. In hydronephrosis, blocked ureters cause urine to build up in the kidneys.) This is the MCCOD in cervical cancer.

Question 193

Key complication of LEEP and conization procedures:

Answer 193

cervical insufficiency (painless pregnancy loss)

Question 194

A 22-year-old woman comes to her primary care physician's office for a follow up of an abnormal Pap smear result. The patient had a Pap smear completed one month ago, which showed a low-grade squamous intraepithelial lesion, and tested positive for double stranded DNA naked icosahedral DNA virus. History reveals she began having sexual intercourse at age 16 and has had 4 lifetime partners. There is no history of sexually transmitted infections or pregnancies. She uses oral contraceptive pills regularly and condoms "most of the time." She denies tobacco or illegal drug use. She has not had any vaccinations for the prevention of sexually transmitted infections. Which of the following is the most appropriate next step of management in this patient? - Loop electrosurgical excision procedure - Hysterectomy - Repeat cervical cytology in 12 months - Repeat Pap smear in 4 months - Colposcopy

Answer 194

Repeat cervical cytology in 12 months HPV, double stranded DNA virus, is the most commonly transmitted sexual infection and is a major cause of cervical cancer. Patients ages 21-24 with a low-grade squamous intraepithelial lesion should be treated conservatively and scheduled for a follow up cytologic screening test in 12 months

Question 195

Cytologic (Pap test) abnormalities are described using the term ———. Histologic (biopsy) abnormalities are described using the term ———.

Answer 195

“squamous intraepithelial lesion” (SIL) “cervical intraepithelial neoplasia” (CIN)

Question 196

A 45-year-old G4P4 patient presents for a routine annual exam. Her Pap test returns with a report of ASCUS. Her Pap tests have always been normal in the past. What is the next best step to evaluate her cancer risk?

Answer 196

High-risk HPV DNA testing. If high-risk HPV DNA testing is “positive,” indicating the presence of a hrHPV strain, then a colposcopy and indicated biopsies should be performed. If the HPV testing is negative, she can be managed as per her age-based protocol.

Question 197

A 35-year-old woman comes to the office because of irregular bleeding since her last period three weeks ago. She says her bleeding is consistently postcoital. Examination shows no abdominal masses and no peripheral edema. Her urethra is normal, and her fecal occult blood test shows no abnormalities. She is not pregnant. Which of the following is the most likely diagnosis? -Uterine fibroids -Urethral caruncle -Ectopic pregnancy -Peri-menopausal bleeding -Cervical neoplasia

Answer 197

Cervical neoplasia may be characterized by postcoital bleeding for about 11% of cases. Postcoital bleeding refers to spotting or bleeding unrelated to menstruation that occurs during or after sexual intercourse. Other causes include cervical polyps, vaginal cancer, or genital infections. (If the bleeding is consistently postcoital, it suggests cervical pathology, such as cervical polyps, cervicitis, or cervical neoplasia.)

Question 198

ACOG Screening Guidelines for cervical cancer in individuals aged 21–29

Answer 198

Individuals aged 21–29 should be screened with cervical cytology (Pap test) alone every 3 years

Question 199

ACOG Screening Guidelines for cervical cancer in individuals aged 30–65

Answer 199

There are now three recommended options for cervical cancer screening in individuals aged 30–65 years: ■ Cytology alone every 3 years. ■ FDA-approved primary hrHPV testing alone every 5 years. ■ Co-testing with cytology and hrHPV testing every 5 years.

Question 200

ACOG Screening Guidelines for cervical cancer in high risk individuals

Answer 200

Frequency of Pap test screening should be individualized, and may need to occur earlier/more often in women who have HIV, are immune compromised, were exposed to diethylstilbestrol (DES) in utero, or have been previously treated for CIN2, CIN3, or cancer.

Question 201

ACOG Screening Guidelines for cervical cancer in women under age 21

Answer 201

Women under age 21 should not be screened, because the incidence of cervical cancer is very low, and they have an effective immune response that will usually clear the HPV infection in 8–24 months.

Question 202

ACOG Screening Guidelines for cervical cancer in women after age 65

Answer 202

Pap tests may be discontinued after age 65 in healthy women with adequate negative prior screening test (Pap test) results and no history of CIN2 or higher.

Question 203

ACOG Screening Guidelines for cervical cancer in women after hysterectomy

Answer 203

A Pap test may be discontinued after hysterectomy (with removal of the cervix) for benign disease.

Question 204

A 15-year-old girl comes to the office for a routine annual physical examination. During the appointment, her mother inquires about the human papillomavirus (HPV) vaccine and is happy for her daughter to get the vaccine today. When her mother steps out of the office, the patient says that she started having sex with her boyfriend about two months ago, and she does not want her mother to know. They have always used condoms and her last menstrual period was eight days ago. Which of the following is the most appropriate next step in management? -Inform the patient's mother that she cannot get the vaccine because she is already sexually active -Do a human papillomavirus test to make sure she has not been infected before she gets the vaccine -Administer a dose today, a second shot in two months, and a third shot in six months - Administer the vaccine anyway, but it will not be effective - Obtain a pregnancy test before administering the vaccine

Answer 204

- Administer a dose today, a second shot in two months, and a third shot in six months The quadrivalent human papillomavirus (HPV) vaccine protects against HPV 6 and 11, which cause 90% of genital warts, and HPV 16 and 18, which cause 70% of cervical cancer cases. Although it is most efficient prior to the onset of sexual activity, it is still recommended for people who are already sexually active. The human papillomavirus (HPV) vaccine is a three-dose series that is currently recommended for girls and boys ages 9-26 (but ideally between 11-12 years of age) to prevent infection with HPV. The quadrivalent vaccine protects against HPV 6 and 11, which cause 90% of genital warts, and HPV 16 and 18, which cause 70% of cervical cancer cases. There is also a bivalent vaccine which only covers HPV 16 and 18. The vaccine has a very good safety profile, and few side effects beyond tenderness at the injection site have been noted. Although the human papillomavirus (HPV) vaccine is contraindicated in pregnancy, routine pregnancy testing is not recommended prior to vaccination. The patient is using contraceptives and her last menstrual period was a week ago, making pregnancy unlikely. She should be urged to continue using contraceptives for the duration of the series. The vaccine is contraindicated in pregnancy because there have not been enough studies of its safety in this group (pregnancy category B). However, in women who were inadvertently vaccinated without prior knowledge of their pregnancy status, there has been no increased risk to the fetus, and there is no need to terminate such a pregnancy. The vaccine series can be completed after the pregnancy.

Question 205

What HPV genotypes are contained in the Gardasil quadrivalent vaccine?

Answer 205

Types 6, 11, 16, and 18 Protects against 70% of cervical cancers and 90% of genital warts (Note: Only the 9-valent vaccine is available in the United States (GARDASIL-9))

Question 206

Administration schedule for HPV vaccine (Gardasil)

Answer 206

Administered as three doses: 0.5 mL intramuscularly given at intervals of 0, 2, and 6 months

Question 207

US Advisory Committee on Immunization Practices (ACIP) recommendations for HPV Vaccines:

Answer 207

1. Routine vaccination at age 11–12, but can be given as early as age 9. 2. For adolescents and adults aged 13–26 years who have not been previously vaccinated or have not completed the series, catch-up vaccination is recommended. 3. For adults 27 years and older, catch-up vaccination is not routinely recommended, and should be made on an individual basis. Not recommended for pregnant women. Can be given to breast-feeding women

Question 208

Management of abnormal Pap tests in women ages ——— differs from those age ——— because of the low incidence of cervical cancer in this age group.

Answer 208

21–24 ≥25

Question 209

CIN1 is a ———. It is referred to as ——— in the LAST system.

Answer 209

low-grade lesion with mild atypical changes in the lower one-third of the epithelium low-grade SIL (LSIL)

Question 210

CIN2 is a ———. Specimens that are p16-negative are referred to as ——— and those that are p16-positive are referred to as ———

Answer 210

high-grade lesion, with atypical changes confined to the lower two-thirds of the epithelium (difficult to differentiate from CIN3; stratified according to p16 immunostaining to identify precancerous lesions) LSIL high-grade SIL (HSIL)

Question 211

CIN3 is a ———, and is referred to as ——— in the LAST system.

Answer 211

high-grade lesion, where atypical cells encompass >2/3 of the epithelium HSIL (CIN2 and CIN3 are often treated the same)

Question 212

A 45-year-old G4P4 patient presents for a routine annual exam. Her Pap test returns with a report of ASCUS. Her Pap tests have always been normal in the past. What is the next best step to evaluate her cancer risk?

Answer 212

High-risk HPV DNA testing. If high-risk HPV DNA testing is “positive,” indicating the presence of a hrHPV strain, then a colposcopy and indicated biopsies should be performed. If the HPV testing is negative, she can be managed as per her age-based protocol.

Question 213

Next step if pap finds atypical squamous cells of undetermined significance (ASCUS):

Answer 213

1. Reflex HPV testing if under age 30, concurrent HPV testing if age 30 and above. 2. If HPV negative—continue routine screening per protocol. 3. If HPV positive—colposcopy if age ≥25, repeat cytology (Pap test) in 1 year if age 21–24.

Question 214

Next step if pap finds atypical squamous cells, cannot exclude HSIL (ASC-H):

Answer 214

Colposcopy with indicated biopsies

Question 215

Next step if pap finds LSIL:

Answer 215

Colposcopy with indicated biopsies if age ≥25, repeat cytology (Pap test) in 1 year if age 21–24

Question 216

Next step if pap finds HSIL:

Answer 216

Colposcopy with endocervical curettage and indicated biopsies

Question 217

List results of an abnormal Pap test in order of severity:

Answer 217

●Atypical squamous cells of undetermined significance (ASC-US) ●Low-grade squamous intraepithelial lesions (LSIL) ●Atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H) ●High-grade squamous intraepithelial lesions (HSIL) ●Atypical glandular cells (AGC)

Question 218

Next step if pap finds atypical glandular cells (AGC):

Answer 218

Colposcopy with indicated biopsies, endocervical curettage (ECC), and endometrial biopsy

Question 219

——— percent of women with abnormal cytologic findings can be adequately evaluated with colposcopy.

Answer 219

Ninety

Question 220

What must be completely visualized for adequate colposcopic evaluation?

Answer 220

1. TZ 2. Extent of lesion in its entirety

Question 221

Define Colposcopy with Cervical Biopsy

Answer 221

A procedure that utilizes staining and a low-magnification microscope, mounted on a stand, for the viewing of the cervix, vagina, and vulva; illuminated, magnified view, which aids in identifying lesions and biopsying suspicious areas to obtain histologic diagnosis. (1. Speculum inserted; 2. Acetic acid applied: The neoplastic cells appear whiter; 3. Colposcopy; 4. Cervical biopsy: Neoplastic and dysplastic areas are then biopsied under colposcopic guidance; 5. ECC: A curette is used to scrape the cervical canal to obtain endocervical cells for cytologic examination.

Question 222

If colposcopy-based biopsy results or ECC is positive for CIN2 or CIN3 (HSIL), then

Answer 222

a cone biopsy or a LEEP should be performed as both a diagnostic and therapeutic procedure

Question 223

A 23-year-old woman, gravida 1, para 1, comes to the office to discuss a recent cervical pap smear from her annual examination. The cytology report says that she has a high-grade squamous intraepithelial lesion (HSIL). She has no complaints and none of her previous cytology reports show any abnormalities. Which of the following tests or treatments is the best next step in managing this patient? -Return in 6 months for repeat pap smear -Human papillomavirus vaccine -Return in 3 months for repeat pap smear -Colposcopy with biopsies -Loop electrosurgical excision procedure

Answer 223

Colposcopy with biopsies Colposcopy and biopsy of any suspected lesions is the best management plan for a woman aged 21-24 years old with a cytological diagnosis of high-grade squamous intraepithelial lesion (HSIL). In women >25 years old, either colposcopy or loop electrosurgical excision procedure (LEEP) would be an appropriate recommendation.

Question 224

A 25-year-old woman comes to the clinic for a Pap smear. She has been treated for multiple sexually transmitted infections in the past. She is sexually active and does not use contraception. Her temperature is 37.0°C (98.6°F), pulse is 80/min, and respirations are 14/min. Physical examination shows no abnormalities. Pelvic examination is normal without evidence of cervical discharge or motion tenderness. A Pap smear is obtained and shows high-grade squamous intraepithelial lesions. Colposcopy is performed and shows cervical intraepithelial neoplasia (CIN) grade 3. Which of the following is the most appropriate treatment for this patient's condition? -Abdominal hysterectomy -Repeat colposcopy to rule out false positive -Vaginal hysterectomy -High dosage of prednisone -Loop electrical excision procedure

Answer 224

Loop electrical excision procedure In patients who have cervical intraepithelial neoplasia (CIN) grade 3, a cervical ablative procedure is the next best step in management. This can be accomplished with a loop electrical excision procedure (LEEP). Excisional or ablative procedures, such as a loop electrical excision procedure (LEEP), laser therapy, cryotherapy, and cervical cone biopsy are appropriate for the management of cervical intraepithelial neoplasia (CIN) grades 2 or 3. CIN 1 lesions often regress spontaneously without further management and only follow up for repeat smear or colposcopy is required. The rate of spontaneous regression of CIN 2 or 3 is lower, warranting a procedure to remove the abnormal cells. If left untreated, CIN may progress to cervical cancer.

Question 225

Cone Biopsy and Loop Electrosurgical Excision Procedure (LEEP) are both excisional procedures which involve

Answer 225

excising a cone-shaped portion of the cervix, including the endocervical canal and TZ (They are intended to be both diagnostic and therapeutic)

Question 226

A 24-year-old woman, gravida 0, para 0, comes to the office for a routine gynecologic examination. She has no specific complaints. Her first pap smear from three years ago showed normal cervical cytology. Last year, she received 3 doses of the human papillomavirus (HPV) vaccine. She is sexually active with two male partners and says that they use condoms intermittently. She is otherwise in good health and her medical history is noncontributory. Her paternal grandmother was diagnosed with cervical cancer at age 55. Which of the following is the most appropriate option for the patient at this time? - Do not perform pap smear at this visit; women do not need routine cervical cytology screening if they have received the human papillomavirus vaccine - Perform pap smear at this visit; women 21-29 years old should receive cervical cytology screening every 3 years - More information about the patient's family history of cervical cancer is needed before a decision can be made about cervical cytology screening - Perform pap smear at this visit; women with multiple sexual partners should receive cervical cytology screening more frequently than the general population - Do not perform pap smear at this visit; women aged 21-29 years old should receive combined cervical cytology screening and HPV co-testing every 5 years

Answer 226

Perform pap smear at this visit; women 21-29 years old should receive cervical cytology screening every 3 years Cervical cytology screening (pap smear) for cervical cancer is recommended every 3 years for women aged 21-29, and cervical cytology plus HPV co-testing every 5 years in women aged 30-65 by the American College of Obstetricians and Gynecologists.

Question 227

Indications for cone biopsy/leep:

Answer 227

■ Inadequate view of TZ on colposcopy ■ Positive ECC ■ Treatment for CIN2–CIN3 (HSIL) ■ Treatment for adenocarcinoma in situ ■ When cancer cannot be excluded after colposcopy, biopsy, and ECC

Question 228

Evaluation of ——— may be challenging with LEEP, because of thermal artifact.

Answer 228

biopsy margins

Question 229

A 25-year-old G1P0 patient at 38 weeks’ gestation presents to triage reporting contractions that have been increasing in strength and frequency over a 12-hour period. She does not have vaginal bleeding, leakage of fluid, or preeclampsia symptoms. She reports good fetal movement. Fetal heart rate (FHR) is reassuring. She is contracting every 2 minutes on the monitor. The cervical exam is 6 cm dilated, 50% effaced, 0 station, cephalic. What stage of labor is she in? If her labor progresses as expected, what should her cervical dilation be at the next vaginal exam (VE) in 2 hours?

Answer 229

She is in the active phase of the first stage of labor. Since she is a primigravida, her cervix should dilate at a minimum of 1.2 cm/hr. So, in 2 hours, she should be 8.4 cm (or 8–9 cm) dilated.

Question 230

Prelabor rupture denotes:

Answer 230

spontaneous rupture of fetal membranes before the onset of labor (Ie, ROM: Rupture of membranes vs PROM: Prelabor rupture of membranes (ROM before the onset of labor)) (Premature ROM can occur at term (PROM) or preterm (PPROM: <37 weeks))

Question 231

Most common diagnosis associated with preterm delivery

Answer 231

PPROM

Question 232

Prolonged rupture of membranes refers to

Answer 232

a rupture of membranes lasting longer than 18 hours (i.e. between time of rupture and time of delivery)

Question 233

Duration of labor is typically shorter in

Answer 233

the multiparous patient than in nulliparous patients

Question 234

Labor is defined as

Answer 234

regular contractions that result in cervical change (A patient can have contractions that do not cause cervical change as well as cervical change without contractions—neither of these are “labor”)

Question 235

Number of stages of labor

Answer 235

There are three stages of labor and two phases of stage 1

Question 236

Describe first stage of labor:

Answer 236

Begins with onset of uterine contractions of sufficient frequency, intensity, and duration to result in effacement and dilation of the cervix, and ends when the cervix is completely dilated to 10 cm. Consists of two phases: 1. Latent phase: Begins with the onset of labor and ends at approximately 4–6 cm cervical dilation. 2.Active phase: Rapid dilation. Ends at 10cm.

Question 237

Describe the second stage of labor

Answer 237

the stage of fetal expulsion: It begins when the cervix is fully dilated and ends with the delivery of the fetus

Question 238

Describe the third stage of labor:

Answer 238

The main event is placental separation: It begins immediately after the delivery of the fetus and ends with the delivery of the fetal and placental membranes (Duration: Usually <10 minutes; considered prolonged if >30 minutes)

Question 239

The three signs of placental separation are:

Answer 239

1. Gush of blood from vagina 2. Umbilical cord lengthening 3. Fundus of the uterus rises up and becomes firm **Know these! They are commonly asked at delivery.**

Question 240

Remember the three “Ps” that affect the duration of the active phase of labor:

Answer 240

■ Power (strength and frequency of contractions) ■ Passenger (size of the baby) ■ Pelvis (size and shape of mother’s pelvis)

Question 241

If progress during the active phase is slower than expected, evaluation for adequacy of ———should be done.

Answer 241

uterine contractions, fetal malposition, or cephalopelvic disproportion (CPD)

Question 242

Abnormalities of the second stage may be either:

Answer 242

protraction or arrest of descent (the fetal head descends <1 cm/hr in a nullipara and <2 cm/hr in a multipara)

Question 243

In third stage of labor, if 30 minutes have passed without placental expulsion, ——— may be required

Answer 243

manual removal of the placenta

Question 244

What are the three signs of placental separation?

Answer 244

1. Gush of blood 2. Umbilical cord lengthening 3. Fundus of uterus rises and firms

Question 245

Contrast true vs false labor in terms of: Regularity of intervals Intensity Location of discomfort Impact on cervix Effect of medications

Answer 245

Question 246

Bloody show is

Answer 246

small amount of blood mixed with cervical mucus that is present with cervical dilation and effacement (should be distinguished from vaginal bleeding)

Question 247

Diagnosis of ROM: The patient’s history alone is correct in ——- of patients. ——— can be mistaken for ROM.

Answer 247

90% Urinary leakage or excess vaginal discharge

Question 248

Spontaneous rupture of membranes (SROM) most often occurs during the course of

Answer 248

active labor

Question 249

A 25-year-old G1P0 patient at 39 weeks’ gestation presents to labor and delivery reporting a gush of fluid from the vagina followed by constant leakage for 2 hours. The fluid is clear and without odor. What tests can help determine whether the patient has ruptured the membranes?

Answer 249

Sterile speculum exam, testing for pooling, ferning, and nitrazine. If these are positive, the membranes are likely ruptured and the fluid noted on the exam is likely amniotic fluid

Question 250

Findings on sterile speculum exam indicative of ROM:

Answer 250

1. Pooling: fluid collection in the posterior fornix or in the posterior blade of the speculum 2. Valsalva: If pooling is not present, ask the patient to bear down and perform a Valsalva maneuver. Note if fluid is seen to come through the cervical os = Positive valsalva. Coughing can work here too. 3. Ferning: Place a thin layer of the vaginal secretions or pooled fluid on a slide. View the dried amniotic fluid under a microscope for a characteristic ferning pattern made by the crystallized sodium chloride in the amniotic fluid (positive ferning). Confirms ROM in 85–98% of cases (see pic for true vs false fern and results when cervical mucous dries in the absence of amniotic fluid). 4. Nitrazine: Place vaginal fluid on nitrazine paper to assess pH. If nitrazine paper turns blue, this indicates basic pH (positive nitrazine). Amniotic fluid has basic pH as compared to vaginal secretions that have acidic pH. Confirms ROM in 90–98% of cases.

Question 251

What can cause a false-positive nitrazine test?

Answer 251

■ Vaginal infections with Trichomonas vaginalis or bacterial vaginosis ■ Blood ■ Semen

Question 252

Define vernix:

Answer 252

The fatty substance consisting of desquamated epithelial cells and sebaceous matter that normally covers the skin of the term fetus. More common in early term infants.

Question 253

Define meconium

Answer 253

A dark green fecal material that collects in the fetal intestines and is discharged at or near the time of birth

Question 254

Meconium staining is more common in

Answer 254

term and postterm pregnancies than in preterm pregnancies

Question 255

Meconium aspiration syndrome (MAS): Define

Answer 255

Fetal stress, like hypoxia, leads to meconium in the amniotic fluid. With further fetal gasping, the meconium is inhaled into the fetal lungs, causing lung damage.

Question 256

Meconium aspiration syndrome (MAS): Presentation

Answer 256

At birth, the infant will present with respiratory distress and can develop pulmonary hypertension.

Question 257

Meconium aspiration syndrome (MAS): Tx

Answer 257

Intubation does not provide adequate oxygenation due to the lung injury and pulmonary hypertension. Infants with MAS may require extracorporeal membranous oxygenation (ECMO) which bypasses the lungs in order to provide oxygen to the baby

Question 258

Cervix dilation describes ———and is determined by ———

Answer 258

Describes the size of the opening of the cervix at the internal os (Ranges: From zero to 10 cm dilated) Determination of dilation: index and/or the middle fingers are inserted in the cervical opening and are separated as far as the cervix will allow. The distance (cervical dilation) between the two fingers is estimated.

Question 259

Cervical Effacement describes ———and is determined by ———

Answer 259

Describes the length of the cervix. With labor, the cervix thins out and softens, and the length is reduced (When the cervix shortens by 50% (to around 2 cm), it is said to be 50% effaced. When the cervix becomes as thin as the adjacent lower uterine segment, it is 100% effaced (think paper-thin)( Determination of effacement: Palpate with finger and estimate the length from the internal to external os

Question 260

Identify each labeled structure

Answer 260

Question 261

A 33-year-old woman comes to the primary care clinic for an annual well-visit examination. She expresses a desire to become pregnant within the next year and inquires about steps she should take to ensure a healthy pregnancy. She has a past medical history of hypertension that is well-controlled with lisinopril. She has never been pregnant or has had prior issues with infertility. Temperature is 37 ºC (98.6 °F), heart rate is 66/min, blood pressure is 115/75 mmHg, and respiratory rate is 14/min. Physical examination is within normal limits. Which of the following is the most appropriate next step in management? -Discontinue lisinopril and start nifedipine -Discontinue lisinopril only after a positive pregnancy test -Continue lisinopril as it is effectively controlling her blood pressure -Increase lisinopril dosage to prevent hypertension-related complications in pregnancy -Continue lisinopril and add oral folic acid supplementation

Answer 261

Discontinue lisinopril and start nifedipine A key component of preconception counseling is to identify use of medications that are teratogenic. Renin-angiotensin system blocking agents are contraindicated in pregnancy and should be discontinued before conception. Patients should be switched to a pregnancy-safe antihypertensive like nifedipine, methyldopa, or labetalol. This patient who is planning on becoming pregnant within the next year should be switched from her current ACE inhibitor to a pregnancy-safe antihypertensive like nifedipine. Agents that block the Renin-angiotensin system, such as ACE inhibitors and angiotensin receptor blockers (ARBs) are contraindicated in pregnancy and should be discontinued before conception.

Question 262

ACE inhibitors and ARBs are contraindicated in pregnancy. These medications have been associated with

Answer 262

neonatal kidney failure and death

Question 263

Antihypertensives that are safe to use in the perinatal period include

Answer 263

nifedipine, methyldopa, and labetalol

Question 264

Patients with long-standing or uncontrolled hypertension who become pregnant should have ———. They should be counseled that they are at an increased risk of developing ——— in pregnancy, and they should be started on ——— to reduce their risk of preeclampsia.

Answer 264

vision screening, urine protein evaluation, and an electrocardiogram preeclampsia and intrauterine growth restriction low-dose aspirin after 12 weeks of gestation

Question 265

Describe station

Answer 265

Describes the degree of descent of the presenting part in relation to ischial spines, which are designated at 0 station. Terminology (two systems): 1. The ischial spine is zero station, and the areas above and below are divided into thirds. Above the ischial spines are stations –3, –2, and –1, with –3 being the furthest above the ischial spines and –1 being closest. Positive stations describe fetal descent below the ischial spines. +3 statian is at the level of the introitus, and +1 is just past the ischial spines. 2. Very similar except that the areas above and below the ischial spines are divided by centimeters, up to 5 cm above and 5 cm below. Above are five stations or centimeters: –5, –4, –3, –2, and –1, with –5 being the 5 cm above the ischial spines and –1 being 1 cm above. Positive stations describe fetal descent below the ischial spines. +5 station is at the level of the introitus, and +1 is 1 cm past the ischial spines. ■ If the fetus is vertex, the station should be determined by the location of the biparietal diameter (BPD), not the tip-top of the head, which may simply be caput and not the head at all. So, when the BPD is at the level of the ischial spines, the station is 0.

Question 266

Define consistency of cervix changes

Answer 266

Changes progressively from firm to medium to soft, in preparation for dilation and labor. For some context: Firm consistency is described like the forehead, medium like the tip of the nose, and soft like the check.

Question 267

Describe changes position of cervix

Answer 267

Describes the location of cervix with respect to the fetal presenting part. ■ Posterior: Difficult to palpate because it is behind the presenting part, and usually high in the pelvis. ■ Midposition. ■ Anterior: Easy to palpate, low in pelvis, pointing forward. During labor, the cervical position progresses from posterior to anterior.

Question 268

Vaginal prostaglandins are inserted for

Answer 268

ripening (softening) of cervix

Question 269

IV pitocin is used to

Answer 269

↑ strength and frequency of contractions (Pitocin is a synthetic oxytocin. It is used to start or enhance labor.)

Question 270

Bishop scoring system used for

Answer 270

helps to determine the status of the cervix—favorable or unfavorable—for successful vaginal delivery (If induction of labor is indicated, the status of the cervix must be evaluated to help determine the method of labor induction; A score of ≥6 indicates that the probability of vaginal delivery with induction of labor is similar to that of spontaneous labor)

Question 271

A 32-year-old woman is evaluated for preconception counseling. She received two doses of the human papillomavirus (HPV) vaccine before 15 years of age; the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine 3 years ago; and the influenza and COVID-19 vaccines during the last influenza season. She has no medical problems and takes no medication. Vital signs are within normal limits and a comprehensive physical examination is within normal limits. Laboratory studies reveal a negative rubella antibody titer and a positive varicella antibody titer. Pregnancy test is negative. Which of the following is the most appropriate next step in management? -Assure her that no additional vaccines are needed before pregnancy -Advise her to wait until after pregnancy to receive the rubella vaccine -Recommend receiving the rubella vaccine immediately after conception -Administer the rubella vaccine at least one month before she attempts to conceive -Administer the varicella vaccine now

Answer 271

Administer the rubella vaccine at least one month before she attempts to conceive Live vaccines (e.g., varicella, MMR) are contraindicated during pregnancy. Women who are planning to become pregnant who do not have immunity to rubella or varicella should receive the respective vaccine before conceiving and should wait at least 4 weeks following vaccination before attempting to conceive. This patient who presents for preconception counseling lacks immunity to rubella. Therefore, she should receive the measles, mumps and rubella (MMR) vaccine at least 4 weeks prior to conception. The rubella vaccine is critical in preconception care, because intrauterine rubella infection can lead to severe birth defects (e.g., hearing loss, cataracts, cardiac abnormalities, bone lesions, growth restriction, and neurologic abnormalities, including intellectual disability) and miscarriage. The rubella vaccine is a live vaccine, and should therefore be administered at least one month before conception to avoid any risk to the fetus and ensure immunity is established before pregnancy. Vaccination against varicella is similar to rubella. The varicella vaccine is a live attenuated vaccine used for primary prevention of chickenpox and the vaccine is not recommended during pregnancy. Ensuring immunity before pregnancy is crucial to avoid significant maternal and fetal complications associated with varicella infection.

Question 272

A 28-year-old G2P1001 patient at 37 weeks complains of severe headaches and black spots in her vision. Her BP are 165/95 and 163/96 and she has 4+ protein on urine dipstick. Her cervical exam is closed, thick, and high. The fetal heart tones are reassuring and she has no contractions. The US shows a fetus that is appropriate for 37 weeks, with normal amniotic fluid index (AFI), and in cephalic position. What is the next best step?

Answer 272

This patient has signs and symptoms of preeclampsia with severe features and should be delivered immediately, especially when term. Induction of labor is a safe option in this care. Patients with preeclampsia can have a seizure at any point before, during, or after labor, so seizure prophylaxis with magnesium sulfate is indicated.

Question 273

Eclampsia defined as

Answer 273

Defined as seizure or coma without another cause in a patient with pre-eclampsia (Eclampsia → hemorrhagic stroke → death)

Question 274

HELLP syndrome: Define

Answer 274

manifestation of preeclampsia with severe features ■ Hemolysis. ■ Elevated Liver enzymes. ■ Low Platelets. (Associated with high morbidity, and immediate delivery is indicated. It may occur with or without HTN.)

Question 275

Timeline for HTN disorders of pregnancy

Answer 275

Hypertensive disorders of pregnancy impact patients AFTER 20 weeks’ gestation. Patients with elevated BP prior to 20 weeks are considered to have chronic HTN.

Question 276

What is the treatment of choice for seizure prophylaxis in pregnant patient with preeclampsia? What is its antidote in case of toxicity on this treatment?

Answer 276

Magnesium sulfate (MgSO4) Calcium gluconate

Question 277

Timeline for diagnosis of chronic HTN relative to pregnancy

Answer 277

■ ↑ BP outside of pregnancy ■ ↑ BP prior to 20 weeks’ gestation ■ ↑ BP persisting after 12 weeks post-partum

Question 278

In pregnancy, BP in severe range should be treated within 30–60 minutes using

Answer 278

Oral nifedipine or IV labetolol or IV hydralazine are all appropriate agents for lowering of severe range BPs

Question 279

Define superimposed preeclampsia:

Answer 279

Preeclampsia in the presence of preexisting chronic HTN. Diagnosed with worsening BPs and new or worsening proteinuria. Patients with chronic HTN are at ↑ risk of developing superimposed preeclampsia.

Question 280

Define Gestational HTN:

Answer 280

HTN without proteinuria or other signs/symptoms of preeclampsia (sustained or transient systolic BP ≥ 140 mm Hg and/or diastolic BP ≥ 90 mm Hg occurs after 20 weeks)

Question 281

Define Preeclampsia:

Answer 281

Defined as new onset HTN with either proteinuria or end-organ dysfunction (or both) after 20 weeks end-organ dysfunction: ■ Thrombocytopenia ■ Serum creatinine >1.1 mg/dL or doubling of serum creatinine. ■ LFTs at least twice the normal concentration. ■ Pulmonary edema. ■ Cerebral or visual symptoms (headache, scotomata). (May qualify for preeclampsia with severe features depending on combination/levels)

Question 282

The only definitive treatment for preeclampsia is

Answer 282

delivery

Question 283

The classic clinical triad of ectopic pregnancy consists of

Answer 283

abdominal pain, amenorrhoea and vaginal bleeding

Question 284

Ectopic pregnancy is often clinically mistaken for ——— as presenting symptoms of pain, nausea, and fever are shared between the two.

Answer 284

Appendicitis

Question 285

The ——— portion of the fallopian tube is the most common site of an ectopic pregnancy.

Answer 285

ampullary

Question 286

——— is a folic acid analog that competitively inhibits dihydrofolate reductase and is used to treat ectopic pregnancy and medical abortion.

Answer 286

Methotrexate

Question 287

Risk factors for ectopic pregnancy include

Answer 287

prior ectopic pregnancy, history of infertility, salpingitis, pelvic inflammatory disease, ruptured appendix prior tubal surgery

Question 288

Define a tubal ring:

Answer 288

echogenic, ringlike structure found outside of the uterus, on ultrasonography, that represents an early ectopic pregnancy

Question 289

——— is the standard medication used in the treatment of an unruptured ectopic pregnancy.

Answer 289

Methotrexate

Question 290

Define a pseudosac:

Answer 290

A collection of fluid within the endometrial cavity created by bleeding from the decidualized endometrium and is often associated with an ectopic pregnancy

Question 291

Kartagener syndrome is a syndrome with ——— that results in infertility and an increased risk of ectopic pregnancy.

Answer 291

immotile cilia due to a dynein arm defect (primary ciliary dyskinesia)

Question 292

If transvaginal US does not show an intrauterine pregnancy when the ——— are reached, the pregnancy can be considered ectopic.

Answer 292

discriminatory β-human chorionic gonadotropin levels

Question 293

Compared to a normal pregnancy, human chorionic gonadotropin is ——— in ectopic pregnancy.

Answer 293

Decreased

Question 294

A 25-year-old woman comes to the office due to vaginal bleeding and abdominal pain for the past 2 days. The patient’s last menstrual cycle was 6 weeks ago. She is sexually active with her male partner of 2 years, and they have been using the withdrawal method as contraception. Medical history is unremarkable other than an episode of pelvic pain 2 years ago that resolved spontaneously without treatment. Temperature is 37.0°C (98.6°F), pulse is 80/min, and blood pressure is 135/85 mmHg. Serum hCG is positive, measuring 1200 mIU/mL. Transvaginal ultrasound shows an empty, normal-appearing uterus and no other abnormalities. Physical examination shows mild lower right adnexal tenderness but is otherwise unremarkable. Which of the following is the underlying cause of this patient’s presentation? -Obstruction of blood flow to the ovary -Abnormal implantation -Premature separation of the placenta -Spread of pelvic inflammatory disease -Incomplete early pregnancy loss

Answer 294

Ectopic pregnancy should be suspected in any woman of reproductive age who presents with abdominal pain and/or vaginal bleeding. The next step is to obtain urine hCG, followed by a transvaginal ultrasound to confirm intrauterine or extrauterine pregnancy. This patient is presenting with abdominal pain, vaginal bleeding, an empty uterus on vaginal ultrasound, and positive hCG, raising concerns for ectopic pregnancy. The history of pelvic pain that resolved spontaneously implies pelvic inflammatory disease that caused tubal scarring, which puts her at risk for ectopic pregnancy. The first step in management in any hemodynamically stable female patient of reproductive age with abdominal pain is to obtain urine/serum hCG. If positive, the next step is to obtain a transvaginal ultrasound to assess for an intrauterine sack. If no intrauterine or ectopic pregnancy have been identified, and hCG levels are below 2000 mIU/mL (discriminatory zone for a gestational sac to be visualized by US), serial quantitative serum hCG levels should be checked every 2 days. hCG levels in normal intrauterine pregnancy should rise ≥35% in 48 hours OR double in 72 hours. Once the levels are above the discrimination zone, transvaginal ultrasound should confirm the diagnosis of ectopic or intrauterine pregnancy. If the patient is hemodynamically unstable at presentation, FAST ultrasound and an emergency surgical consultation are appropriate.

Question 295

Ovarian torsion refers to ———. The classic presentation is ———.

Answer 295

rotation of the ovary and its ligament, leading to the impedance of the blood supply acute onset of pelvic pain, nausea, and vomiting, as well as an adnexal mass

Question 296

Though many patients have a lot of ——— associated with preeclampsia, this is NOT part of the diagnostic criteria.

Answer 296

edema

Question 297

Preeclampsia with severe features is defined by the presence of one of the following:

Answer 297

Severe BP elevation: systolic ≥160 or diastolic ≥110 at least 4 hour apart (if only BP) OR Systolic ≥140 or diastolic ≥90 twice at least 4 hour apart AND other severe sxs, including ■ Neurologic dysfunction: headache, scotomata, altered mental status. ■ Renal abnormality: serum creatinine >1.1 mg/dL or doubling of serum creatinine. ■ Hepatic abnormality: Epigastric or RUQ pain (hepatocellular ischemia and edema that stretches Glisson’s capsule), ↑ AST, ALT ≥ twice the normal level, or both. ■ Pulmonary edema. ■ Thrombocytopenia

Question 298

Define superimposed preeclampsia:

Answer 298

■ Defined by new onset of either proteinuria or end-organ dysfunction after 20 weeks in a patient with chronic HTN. ■ For patients with chronic HTN who have preexisting proteinuria, superimposed preeclampsia is defined by worsening HTN or development of severe features (Patients with chronic HTN are at ↑ risk of developing superimposed preeclampsia.)

Question 299

Relationship between preeclampsia and eclampsia?

Answer 299

Eclampsia is considered a form of severe preeclampsia. More commonly it is NOT preceded by preeclampsia.

Question 300

Effect of Magnesium sulfate in preeclampsia

Answer 300

Magnesium sulfate prevents seizures in preeclampsia; does not treat HTN.

Question 301

Magnesium toxicity is associated with sxs of ———. Treat with ———.

Answer 301

loss of patellar reflexes, respiratory depression, and cardiac arrest calcium gluconate IV

Question 302

Complication HTN in pregnancy

Answer 302

■ Placental abruption ■ Eclampsia ■ Coagulopathy ■ Renal failure ■ Hepatic subcapsular hematoma ■ Uteroplacental insufficiency and fetal growth restriction

Question 303

HTN may be absent in ——— of patients with HELLP syndrome and severe in ———.

Answer 303

20% 50%

Question 304

Objectives in management of severe preeclampsia:

Answer 304

1. Prevent eclampsia which can cause intracranial hemorrhage and damage to other vital organs 2. Deliver a healthy infant

Question 305

Eclampsia: ■ ——— of seizures are before labor. ■ ——— of seizures are during labor. ■ ——— of seizures are post-delivery (most occur within 1 week of delivery).

Answer 305

60% 20% 20%

Question 306

ACE inhibitors used to control HTN in pregnancy?

Answer 306

ACE inhibitors are contraindicated because they are teratogenic. Use other classes of antihypertensives to control HTN in pregnancy.

Question 307

Importantly, with HELLP syndrome ——— is indicated.

Answer 307

immediate delivery

Question 308

HELLP syndrome may occur with or without ———

Answer 308

HTN.

Question 309

A 33-year-old woman, gravida 1, para 0, of 29 weeks' gestation comes to the emergency room because of a tonic-clonic seizure. She is accompanied by her husband, who says that he has never witnessed her having a seizure before. Her temperature is 37.3°C (99.3°F), pulse is 100/min, respirations are 18/min, and blood pressure is 155/105 mm Hg. Physical examination shows bilateral patellar hyperreflexia. Laboratory analysis shows the following selected values: Alanine aminotransferase (ALT): normal Aspartate aminotransferase (AST): normal Total bilirubin: elevated Direct bilirubin: elevated Hemoglobin: normal Erythrocytes: 5,100,000/mm3 Leukocytes: 9,000/mm3 Platelets: low Urine protein: elevated Urine erythrocytes: none Urine leukocytes: none Which of the following is the most appropriate diagnosis? -Hemolysis, elevated liver enzymes, and low platelets syndrome -Thrombotic thrombocytopenic purpura -Eclampsia -Placental abruption -Pre-eclampsia

Answer 309

Eclampsia Eclampsia is characterized by hypertension, proteinuria and seizures after the 20th week of gestation. Definitive treatment is delivery of the baby after maternal stabilization, but further seizures can be prevented with intravenous magnesium sulfate. Pre-eclampsia is a disorder of pregnancy defined by hypertension (>140/90) and end-organ dysfunction after the 20th week of gestation to 6 weeks postpartum. End-organ dysfunction can manifest as proteinuria (>0.3 g/24 h urine collection), platelet count <100,000/mm3, or serum transaminase level >2 times normal concentration. Preeclampsia is caused by abnormalities in the placental spiral arteries, which can result in maternal endothelial dysfunction, vasoconstriction or hyperreflexia. One complication of pre-eclampsia is eclampsia, which occurs when a patient with pre-eclampsia experiences new-onset generalized tonic-clonic seizures. Eclampsia-associated seizures places mother at an increased risk for stroke. Eclampsia should be treated with IV magnesium sulfate to prevent seizures, antihypertensives, and expedited delivery if necessary.

Question 310

Antihypertensives in pregnancy: drugs, mechanisms, keys side effects

Answer 310

Short-Term Control: ■ Hydralazine: direct vasodilator Side effects: SLE-like syndrome, headache, palpitations ■ Labetalol: nonselective β1 and α1 blocker. Side effects: headache and tremor. ■ Nifedipine: calcium channel blocker. Side effects: edema, dizziness. Long-Term Control ■ Nifedipine ■ Labetalol (can exacerbate asthma)

Question 311

Risk Factors For HTN Disorders of Pregnancy

Answer 311

■ Nulliparity ■ Age<16 or >40 years ■ Family history of preeclampsia in first degree relative ■ Chronic HTN ■ Chronic renal disease ■ Antiphospholipid syndrome ■ Diabetes mellitus ■ Multiple gestation ■ History of preeclampsia in prior pregnancy

Question 312

Reactive NST:

Answer 312

15 bpm above the baseline lasting 15 seconds; 2×/20 minutes

Question 313

A 27-year-old woman at 38 weeks of gestation comes to the emergency department with three days of right upper quadrant abdominal pain, nausea, vomiting and fatigue. She had preeclampsia in a prior pregnancy but has an otherwise unremarkable medical history. Her blood pressure is 145/87 and lab studies show anemia with Hgb levels 9.5 g/dL, thrombocytopenia with a platelet count of 55,000/mm3. Liver function tests are abnormal with AST levels at 180u/L, ALT levels at 200u/L, and total bilirubin at 2.0 mg/dL (direct bilirubin is 0.1 mg/dL). A blood smear reveals schistocytes. The patient is admitted to labor and delivery, where fetal testing reveals a heart rate of 95 bpm with minimal baseline variability and late decelerations. Which of the following is the most appropriate next step in management? -Give ursodeoxycholic acid -Expectant management -Caesarian section -Monitor enzyme levels closely until delivery date -Platelet transfusion

Answer 313

HELLP syndrome is characterized by the presence of hemolysis, elevated liver enzymes, and low platelets. In this situation, an emergency caesarian section is indicated. This patient is suffering from HELLP syndrome, as indicated by the presence of hemolysis, elevated liver enzymes, and low platelets. The etiology of this disorder is not well-understood, but it is believed to be part of the spectrum of preeclampsia/eclampsia disorders. Therefore, like severe preeclampsia, HELLP syndrome may also constitute an indication for emergency delivery in order to avoid further complications and maternal mortality, particularly if there are also signs of fetal distress. In this case, the fetus is at term (38 weeks) and is presenting with bradycardia and late decelerations. Therefore, it is necessary to proceed with caesarian section for the sake of both mother and fetus.

Question 314

The non-stress test ( NST) evaluates what four components of the FHR tracing:

Answer 314

■ Baseline: Normal is 110–160 beats/min. ■ Variability: Beat-to-beat variation of the FHR. Presence of variability reflects an intact and mature brain stem and heart ■ Decelerations: - Early deceleration: Vagally mediated, caused by head compression usually at cervical dilation of 4–7 cm. - Variable deceleration: Caused by cord compression. - Late deceleration: Reflects uteroplacental insufficiency. ■ Acceleration: Presence of accelerations = fetal well-being. Reactive NST = two or more accelerations over 20 minutes.

Question 315

——— decreases plasma bile acid levels is used to relieve pruritus and treat intrahepatic cholestasis of pregnancy

Answer 315

Ursodeoxycholic acid

Question 316

Baseline rate for the FHR refers to:

Answer 316

the most common heart rate over the last ≥10 minutes

Question 317

The normal baseline for the FHR is

Answer 317

110–160 beats per minute (bpm)

Question 318

Periodic changes above and below baseline FHR are termed

Answer 318

accelerations (↑ in HR) and decelerations (↓ in HR)

Question 319

A reassuring NST has

Answer 319

two accelerations of at least 15 bpm above the baseline, lasting for at least 15 seconds, in 20 minutes (It indicates a well-oxygenated fetus with an intact neurological and cardiovascular system)

Question 320

When reading the fetal tracing, always note the following:

Answer 320

1. Baseline 2. Variability 3. Presence of accelerations 4. Presence of decelerations 5. Contractions

Question 321

NST for fetus <28 weeks’ gestation

Answer 321

A fetus <28 weeks’ gestation age is neurologically immature and thus is not expected to have a “reactive” FHR. Thus, an NST is not a good test for fetal well-being in this population.

Question 322

A 29-year-old woman, gravida 2, para 1, at 32 weeks' gestation comes to the office because of mild abdominal pain in her right upper quadrant for the past three days. She has vomited twice since her pain started. Her temperature is 36.8°C (98.2°F), pulse is 88/min, respirations are 16/min, and blood pressure is 150/95 mm Hg. Physical examination shows facial puffiness as well as right upper quadrant tenderness that radiates into the epigastric area. A urinalysis shows 3+ proteinuria. Which of the following sets of laboratory values are most appropriate to make the diagnosis? -Elevated fasting glucose level and elevated liver enzymes -Low platelet count and elevated magnesium level -Low white blood cell count and elevated liver enzymes -Low platelet count and elevated liver enzymes -Elevated blood urea nitrogen and elevated creatinine

Answer 322

Low platelet count and elevated liver enzymes Preeclampsia refers to hypertension with proteinuria and edema in a pregnant woman that arises in the third trimester of pregnancy. It can lead to hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. Preeclampsia is a hypertensive disorder associated with pregnancy that manifests after the 20th week of gestation. It is characterized by a combination of hypertension, proteinuria and nondependent edema in a pregnant woman. The presence of right upper quadrant (RUQ) pain further suggests the development of hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, which occurs in about 10-20% of patients with severe preeclampsia. Patients with HELLP syndrome commonly experience nausea, vomiting, and malaise in addition to the features associated with preeclampsia. All of the following criteria must be met for a diagnosis of HELLP syndrome: Microangiopathic hemolytic anemia with schistocytes on blood smear Platelets <100,000/μL Total bilirubin >1.2 mg/dL Serum aspartate aminotransferase (AST) >twice the upper limit of normal

Question 323

Early Decelerations: significance, when, why, initial tx

Answer 323

significance: benign when: Nadir of decel = Peak of contraction why: head compression initial tx: none required

Question 324

Variable Decelerations: significance, when, why, initial tx

Answer 324

significance: Variable when: Variable why: cord compression initial tx: aminotransfusion (Infuse normal saline into the uterus through the IUPC to alleviate cord compression)

Question 325

Late Decelerations: significance, when, why, initial tx

Answer 325

significance: abnormal when: gradual decrease below the baseline with onset, nadir, and recovery occurring after uterine contraction onset, peak, and recovery why: Uteroplacental insufficiency (blood without enough oxygen) initial tx: O2, lateral decubitus position, Pitocin off, close monitoring

Question 326

The ——— position is best for maximizing cardiac output and uterine blood flow.

Answer 326

left lateral recumbent (In the supine position, the vena cava and aortoiliac vessels may be compressed by the gravid uterus.)

Question 327

STOP when you see decelerations:

Answer 327

SVE. Turn the patient to her left side. Give the patient Oxygen. Pitocin off.

Question 328

A 30-year-old woman, gravida 2 para 1, comes to the labor and delivery triage at 37 weeks gestation due to mild vaginal bleeding for the past 2 hours. She has not had any pain but has had occasional, non-painful contractions. She did not receive prenatal care but states that she took prenatal vitamins throughout the pregnancy. The patient’s firstborn was delivered via cesarean section. Temperature is 37.0°C (98.6°F), pulse is 100/min, and blood pressure is 115/80 mmHg. On physical examination, the patient appears comfortable. The uterus is soft and nontender. Streaks of blood are seen in the vaginal vault with no active bleeding. The fetus is in a vertex position. The fetal heart rate is 150 bpm. Which of the following is the most likely diagnosis? -Placental abruption -False labor -True labor -Placenta accreta -Placenta previa

Answer 328

Placenta previa Placenta previa refers to placental tissue implantation over, or in proximity to, the cervical os. Placenta previa should be suspected in any pregnant woman who presents with painless vaginal bleeding after 20 weeks of gestation. Diagnosis is made via ultrasound, and a cesarean section is typically necessary for delivery. This patient is presenting with painless vaginal bleeding in the 3rd trimester, favoring the diagnosis of placenta previa. Placenta previa refers to placental tissue implantation over the internal cervical os, covering all or part of the cervix. The classic presentation is painless late-pregnancy vaginal bleeding. Normally, the placenta implants in the upper uterus, and although it is unclear why it implants in the lower uterus in placenta previa, one hypothesis suggests that areas of suboptimal vascularity in the upper uterine cavity from previous damage (e.g. surgery) promotes implantation in the lower part. Significant risk factors include previous cesarean deliveries, previous uterine surgery, multiple gestations, and previous placenta previa. It is important to note that the presence of pain and tender uterus makes the diagnosis of placenta previa unlikely. The vast majority of placenta previas are identified on ultrasound examination before 20 weeks gestation and typically resolve spontaneously before delivery. In asymptomatic patients < 37 weeks of gestation, management includes follow up with transvaginal ultrasound. If the previa resolves, routine prenatal care can resume. In unstable patients with severe bleeding or evidence of fetal distress, emergent cesarean surgery is indicated. In patients whose previa does not resolve, cesarean section is the preferred method of delivery to avoid postpartum hemorrhage.

Question 329

Placenta accreta refers to a placenta that ———. Placenta accreta presents as a:

Answer 329

attaches to the myometrium without penetrating it life-threatening hemorrhage that occurs after delivery when manual placental separation is attempted

Question 330

"False labor," also known as———, refers to

Answer 330

Braxton-Hicks contractions regular or irregular painful contractions without cervical dilation

Question 331

Placental abruption is the ———. Typical presentation includes:

Answer 331

premature separation of the placenta from the uterine wall that occurs after 20 weeks gestation acute onset of abdominal pain, vaginal bleeding (although bleeding may be concealed), uterine contractions, and uterine tenderness

Question 332

Placenta previa is defined as the attachment of placenta to the

Answer 332

lower uterine segment over the internal cervical os

Question 333

Placenta previa presents with

Answer 333

painless bleeding, most commonly after 20 weeks of gestation

Question 334

———(drug class) are used to help the fetal lung mature in patients with placenta previa

Answer 334

Corticosteroids

Question 335

Placenta previa presents with painless bleeding most commonly in the ——— trimester.

Answer 335

third

Question 336

——— (type) of placenta previa is when the placenta is within 2 cm of the internal cervical os but does not fully cover it.

Answer 336

Marginal

Question 337

A 26-year-old woman comes to the emergency department because of lower abdominal pain and vaginal bleeding for the past 24 hours. Her last menstrual period was 7 weeks ago. She is sexually active with her boyfriend and they use condoms intermittently. Physical examination reveals mild tenderness in the left lower quadrant and left adnexa. The cervix is closed with dried blood visible at the os; there is no active bleeding. A quantitative serum B-HCG is 1,500 IU/L. Transvaginal sonography of the patient's left adnexa reveals an extra-uterine gestational sac with a diameter of 2 cm. Which of the following is the most appropriate management option for this patient? Laparoscopic salpingectomy Open salpingectomy Misoprostol Suction and curettage Intramuscular methotrexate

Answer 337

Intramuscular methotrexate Medical management of ectopic pregnancy using methotrexate is an option for hemodynamically stable women with a small gestational sac and low b-hCG levels. There are three possible approaches to treatment of ectopic pregnancy: medical, surgical, and expectant management. Methotrexate is a folic acid antagonist that inhibits cell replication therapy and is used intramuscularly for medical management of ectopic pregnancy. This treatment option requires careful patient selection and is most successful in patients with a b-hCG is <2000 IU/L, and a gestational sac <3.5cm. Medical management is not an option if the patient is not hemodynamically stable. There are several contraindications, including liver and kidney disease, and it is important that the patient has access to and is willing to engage with the required follow up. Surgical management is indicated for any patient who is medically unstable, is hemorrhaging, has a gestational sac >3.5cm, or a higher b-hCG level (making medical management is more likely to fail). Laparoscopic and open salpingectomy or salpingostomy are the various options for surgical management. Expectant management is reserved for those patients presenting with symptoms and signs suggestive of ectopic pregnancy but who do not have the expected rise in b-hCG or a visible ectopic mass. These patients undergo regular b-hCG monitoring to ensure the levels are decreasing and are followed until the levels reach zero.

Question 338

A 32-year-old G2P1001 patient at 40 weeks’ gestation presents to labor and delivery with contractions. She is noted to be 5 cm dilated, 50% effaced, –1 station, and cephalic. The monitor shows contractions every 2 minutes, and the FHR pattern shows a baseline of 150 bpm, minimal variability, and decelerations that nadir after the peak of the contractions. No accelerations are noted. What is the most likely cause of the findings on the FHR? What is the next step in management?

Answer 338

Uteroplacental insufficiency is the most likely cause for this patient’s late decelerations. The patient should be turned on her left side to maximize oxygenation to the fetus. IV fluid bolus can be given. If her membranes are ruptured, a fetal scalp electrode and an IUPC (internal monitors) will help with the FHR monitoring.

Question 339

Criteria for fetal tachycardia

Answer 339

If an FHR of 160 bpm lasts for ≥10 minutes, then tachycardia is present.

Question 340

Passive immunity for fetus provided by transplacental crossing of ———

Answer 340

IgG (IgG “goes” across the placenta)

Question 341

——— is the antibody present in breast milk.

Answer 341

IgA

Question 342

Key complication of varicella zoster infection and tx?

Answer 342

Can cause pneumonia treat with IV acyclovir

Question 343

Varicella vaccine administration during pregnancy?

Answer 343

Varicella vaccine is a live vaccine, so cannot be used in pregnancy.

Question 344

Varicella infection can cause severe maternal ——— in pregnancy.

Answer 344

pneumonia

Question 345

In pregnancy, post-exposure prophylaxis with ——— within 10 days of exposure is indicated for those who are exposed and susceptible

Answer 345

VZIG (varicella-zoster immune globulin)

Question 346

A 25-year-old G1P0 patient at 15 weeks’ gestation reports that she came in contact with a child that had chickenpox 2 days ago. She does not recall ever having chickenpox or the vaccine. What is the next step?

Answer 346

She should be tested for the presence of varicella antibodies. Many people are immune to chickenpox, but do not recall ever having it or being vaccinated. If testing indicates that she lacks the antibodies, she should receive the varicella immunoglobulin within 96 hours. If she has the varicella antibodies, nothing further needs to be done

Question 347

Any pregnant patient exposed to influenza should receive prophylaxis with

Answer 347

neuraminidase inhibitor (oseltamivir or zanamivir)

Question 348

Influenza vaccine in pregnant patients?

Answer 348

Inactivated influenza vaccine should be given to all pregnant patients at any GA.

Question 349

Parvovirus (B19) causes

Answer 349

erythema infectiosum or fifth disease

Question 350

Parvovirus (B19) presentation

Answer 350

Flulike symptoms are followed by bright red rash on the face—slapped-cheek appearance. Rash may become lacelike, spreading to trunk and extremities.

Question 351

——— in a fetus after parvovirus infection is due to aplastic anemia.

Answer 351

Hydrops

Question 352

Fetal hydrops =

Answer 352

Collection of fluid in two or more body cavities: ■ Scalp edema ■ Pleural effusion ■ Pericardial effusion ■ Ascites

Question 353

A 35-year-old G4P2012 patient at 26 weeks is diagnosed with anti Kell antibodies with the titer of 1:32. Amniocentesis shows that the fetus is positive for the Kell antigen. In addition to antenatal (i.e., biophysical profile), what other testing is critical for this fetus?

Answer 353

The fetus should be monitored with middle cerebral artery (MCA) Dopplers, which indicate the severity of anemia.

Question 354

A 30-year-old G2P1001 patient at 24 weeks’ gestation presents with a bright red rash on both of her cheeks that started yesterday. She reports a 2-day history of fever of 100.4°F (38°C) and lethargy. On physical exam, she is afebrile and has a fine erythematous, lacelike rash on her arms. What is the most likely diagnosis? What is the risk to the fetus?

Answer 354

Flulike symptoms, slapped cheek rash, and fine reticular rash (erythema infectiosum) are a classic presentation for parvovirus infection. The fetus is at risk for aplastic anemia, which can cause nonimmune hydrops and fetal death.

Question 355

A 29-year-old G2P1001 patient at 16 weeks presents for prenatal care. Her blood type is A negative and she has a positive antibody screen. What is the next step in management?

Answer 355

Identify the antibody. Some can be dangerous for the fetus and some are benign. (every patient should have her blood type, Rh status, and antibody screen evaluated at the initial prenatal visit)

Question 356

List key antibodies that pose no harm to the fetus vs antibodies that can cause hemolytic disease of the newborn (HDN) and can be fatal?

Answer 356

antibodies that pose no harm to the fetus: anti-Lewis antibodies that can cause hemolytic disease of the newborn (HDN) and can be fatal: anti-D, anti-Kell, anti-Duffy (Maternal antibodies: Kell Kills, Duffy Dies, Lewis Lives)

Question 357

What Is Rh or D?

Answer 357

The surface of the human RBC may or may not have a Rho (Rh) antigen. If a patient with blood type A has a Rho antigen, the blood type is A+. If that person has no Rho antigen, the blood type is A–

Question 358

If the mother is D negative and the father is D positive, baby will be

Answer 358

there may be a chance that the baby may be D positive

Question 359

If the mother is D negative and her fetus is D positive:

Answer 359

she may become sensitized to the D antigen and develop antibodies against the baby’s RBCs. In her next pregnancy, if the baby is D positive, these antibodies cross the placenta and attack the fetal RBCs, resulting in fetal RBC hemolysis

Question 360

Disease process known as HDN

Answer 360

fetal RBC hemolysis results in significant fetal anemia, resulting in fetal heart failure, hydrops, and death

Question 361

What is the most appropriate timeframe for the following prenatal tests/interventions: Rh (D) immune globulin in an Rh- female

Answer 361

28 weeks (not for Rh- mom + Rh- dad)

Question 362

What is nuchal cord?

Answer 362

Nuchal cord occurs when loops of umbilical cord wrap around the fetal neck.

Question 363

Kleihauer-Betke test determines

Answer 363

the number of fetal RBCs in the maternal circulation

Question 364

MOA RhoGAM

Answer 364

When a patient is given a dose of anti-D IgG, the antibodies bind to the fetal RBCs that have the D antigen on them and clear them from the maternal circulation. The goal is to prevent the patient’s immune system from recognizing the presence of the D antigen and forming antibodies against it.

Question 365

RhoGAM indication:

Answer 365

Give to D-negative patients, who have not formed antibodies against D antigen. (Not indicated for patients who already have anti-D antibodies and are sensitized.) (Indicated for patients who might be sensitized to other blood group antigens.)

Question 366

Critical titer for antibody screen in pregnant women:

Answer 366

1:16

Question 367

Kleihauer-Betke (KB) test estimates the ———. The dose of ——— is based on the results of the KB test.

Answer 367

number of fetal RBCs that are present in the maternal circulation anti-D IgG

Question 368

Hemolytic Disease of the Newborn: HDN/fetal hydrops occurs when

Answer 368

Mother lacks an antigen present on the fetal RBC → fetal RBCs in maternal circulation trigger an immune response → maternal antibodies lyse fetal RBCs → fetal anemia → fetal hyperbilirubinemia + kernicterus + heart failure, edema, ascites, pericardial effusion → death

Question 369

Antibody screen for D-Negative patient should be done at: If antibody screen negative:

Answer 369

the initial prenatal visit and again at 28 weeks the fetus is to be D positive, and one dose of anti-D IgG immune globulin is given to the mother at 28 weeks to prevent development of maternal antibodies

Question 370

At birth, the infant’s D status is tested. If the infant is D negative, ———. If the infant is D positive, ———.

Answer 370

no anti-D IgG is given to the mother anti-D IgG is given to the mother within 72 hour of delivery (The dose of anti-D IgG is determined using a KB test)

Question 371

If the antibody titer for pregnant women is ——— and/or rising, the likelihood of HDN is high. ——— is recommended.

Answer 371

≥1:16 Amniocentesis

Question 372

If during serial US monitoring for fetal anemia (bc prior positive antibody testing), evidence of fetal anemia on MCA Dopplers:

Answer 372

Proceed with inutero blood transfusion (IUT). At this time, assessment of fetal antigen status can be performed if not done previously. If close to term, consider delivery.

Question 373

——— deserve prophylactic Rh (D) immune globulin (even before 28 weeks).

Answer 373

Invasive procedures (say amniocentesis)

Question 374

With the use of anti-D immune globulin, there is an ↑ of isoimmunization caused by minor antigens acquired by incompatible blood transfusion. Those antigen that can cause HDN are managed the same way as anti-D isoimmunized mothers. ——— isoimmunization is an exception because: (3)

Answer 374

Kell ■ It results in more severe anemia than alloimunization due to other erythrocyte antigens because it also causes fetal marrow suppression in addition to hemolysis. ■ Maternal Kell antibody titers are not predictive of the severity of fetal anemia in the same way that titers are with anti-D sensitization. ■ MCA Dopplers are accurate in predicting severe anemia with Kell isoimmunization.

Question 375

A 29 yo G2P1 F presents for her first prenatal visit at 10 weeks gestation. She is Rh (D) -ve. Her anti-D immune globulin titer is negative. What is the NBSIM of this patient?

Answer 375

Leave things as is. Prevent sensitization by administering Rh (D) immune globulin at 28 weeks. Give this earlier if mom has a potential baby blood-mom’s blood mixing procedure like an amniocentesis, miscarriage, etc.

Question 376

A 29 yo G2P1 F presents for her first prenatal visit at 10 weeks gestation. She is Rh (D) -ve. She has a +ve anti-D immune globulin titer. What is the NBSIM of this patient?

Answer 376

Get the dad’s blood type. If it’s -ve, the fetus has to be RH -ve. You won’t need to do anything. If the paternal blood type is Rh (D) +ve, there is a good chance the fetus will be Rh (D) +ve. There are some details along the way that are probably “too detailed” for the shelf but a “high anti-RhD titer in mom” should prompt tests for fetal anemia (like a doppler US of the MCA or sampling of fetal blood). If the fetus is anemic, consider an intrauterine blood transfusion and/or delivery.

Question 377

C

Question 378

Most common causes of PID

Answer 378

Rarely is a single organism responsible for PID (most infections are polymicrobial), but always think of chlamydia and gonorrhea first (these are most common)

Question 379

2 Requirement for a clinical diagnosis of PID:

Answer 379

1. Lower abdominal or pelvic pain 2. Adnexal, uterine, or cervical motion tenderness on exam

Question 380

CMT is a significant clinical finding that often indicates

Answer 380

peritoneal irritation (CMT, uterine and/or adnexal tenderness are defining characteristics of acute symptomatic PID)

Question 381

Define PID

Answer 381

Inflammation of the female upper genital tract (uterus, tubes, ovaries, ligaments) caused by ascending infection from the vagina and cervix

Question 382

PID may lead to

Answer 382

tubal scarring and an increased risk of ectopic pregnancy and/or infertility

Question 383

Remember, any reproductive-aged (approximately 15–55 years) female who presents with abdominal or pelvic pain should

Answer 383

always get a urine pregnancy test

Question 384

RFs PID (5)

Answer 384

■ Age <25 years ■ Multiple sexual partners ■ STI in the partner ■ Unprotected intercourse ■ History of STI or PID

Question 385

Presentation PID

Answer 385

■ Lower abdominal or pelvic pain ■ Adnexal, uterine, or CMT ■ Oral temperature >101°F ■ Purulent cervical or vaginal discharge ■ It should also be noted that PID can be asymptomatic or subclinical. In these cases, PID sequelae (adhesions or hydrosalpinx) are most often identified later during evaluation for infertility or abdominal surgery for other indications.

Question 386

Lab findings in PID

Answer 386

■ Gram stain of discharge with gram-negative diplococci (Neisseria gonorrhoeae) ■ Presence of abundant WBCs on microscopy of vaginal secretions ■ Pelvic abscess (i.e., tuboovarian abscess or TOA) ■ Elevated WBC count ■ Culture evidence of N. gonorrhoeae or C. trachomatis. (Positive lab tests are not necessary for diagnosis. PID is a clinical diagnosis)

Question 387

Laparoscopy findings in PID

Answer 387

Not often performed to diagnose PID, but may be helpful in patients who do not respond to antibiotic therapy, or in whom the diagnosis is not clear and other diagnoses need to be excluded (i.e., appendicitis). ■ Reveals pus draining from the fallopian tubes, edema, adhesions, purulent drainage in the cul-de-sac. ■ perihepatic inflammation, known as Fitz–Hugh–Curtis syndrome

Question 388

Fitz–Hugh–Curtis syndrome (perihepatic inflammation)?

Answer 388

Ten percent of patients with acute PID will develop perihepatic inflammation, known as Fitz–Hugh–Curtis syndrome. “Violin string” adhesions can be seen at the liver capsule on laparoscopy with this syndrome. Often seen months to years later during laparoscopy for other indications.

Question 389

Association between IUDs and PID

Answer 389

Intrauterine devices (IUDs) do NOT increase the risk of PID.

Question 390

Criteria for Hospitalization with PID

Answer 390

■ Peritonitis or surgical emergency cannot be excluded. ■ GI sxs, i.e., nausea, vomiting (inability to take oral meds). ■ Abscess (TOA or pelvic). ■ Uncertain diagnosis. ■ Outpatient treatment failure. ■ Immunocompromised. ■ High fever >100.9°F, severe pain.

Question 391

Criteria for hospitalization for PID:

Answer 391

GI symptoms Uncertain diagnosis Peritonitis Abscess

Question 392

Inpatient tx for PID

Answer 392

■ Cefoxitin/cefotetan + doxycycline. ■ Clindamycin + gentamicin.

Question 393

Outpatient for PID

Answer 393

■ Ceftriaxone + doxycycline ± metronidazole. ■ Cefoxitin + probenecid + doxycycline ± metronidazole. ■ Sexual partners should also be treated empirically.

Question 394

Adjunctive care recommendations for PID

Answer 394

■ Refrain from intercourse until completed antibiotic therapy. ■ Screen for other STIs. ■ Vaccinate against hepatitis B and HPV if the patient has not been vaccinated previously.

Question 395

Chadwick's sign

Answer 395

Pelvic examination revealing a bluish color of the vaginal wall and cervix - pregnancy sign

Question 396

Key history for ectopic pregnancy

Answer 396

history of STI alone or with pelvic inflammatory disease

Question 397

Unruptured ectopic pregnancy classically presents with

Answer 397

lower abdominal pain, vaginal bleeding, and abnormal menstrual history (Physical examination may be completely normal, however classic signs are diffuse abdominal tenderness and unilateral adnexal or cervical motion tenderness)

Question 398

Ruptured ectopic pregnancies are a surgical emergency. On physical exam, ——— suggests intraperitoneal bleeding and ——— correlates with the degree of blood loss

Answer 398

abdominal guarding hypotension

Question 399

A 22-year-old woman presents to the emergency department for evaluation of bilateral lower abdominal pain for 3 days and vaginal discharge. Today she developed nausea and vomiting. She states that she has multiple sexual partners with inconsistent use of condoms. Past medical history is unremarkable. Vital signs are within normal limits. Physical examination reveals lower abdominal tenderness, without rebound or guarding. Labs are ordered and pending. Urine HCG is negative for pregnancy. Which of the following additional findings is most likely to be present on physical examination? -Thick white discharge on speculum examination -Cervical motion tenderness -Vaginal bleeding -Rovsing sign -Positive fluid wave

Answer 399

PID can be clinically diagnosed if cervical motion, uterine, or adnexal tenderness is noted on physical examination in a patient with a clinical picture that is consistent with PID. This patient presents with lower abdominal pain and vaginal discharge for 3 days, as well as nausea and vomiting. Given her symptoms, sexual history, and negative pregnancy test, PID is the most likely diagnosis. Examination findings characteristic of PID include lower abdominal tenderness and adnexal, cervical motion, and uterine tenderness. A clinical diagnosis of PID can be made if any of the following is present on pelvic exam: cervical motion tenderness, uterine tenderness, or adnexal tenderness in a patient with a clinical picture that is consistent with PID. This patient presents with lower abdominal pain and vaginal discharge for 3 days, as well as nausea and vomiting. Given her symptoms, sexual history, and negative pregnancy test, PID is the most likely diagnosis. Examination findings characteristic of PID include lower abdominal tenderness and adnexal, cervical motion, and uterine tenderness. A clinical diagnosis of PID can be made if any of the following is present on pelvic exam: cervical motion tenderness, uterine tenderness, or adnexal tenderness in a patient with a clinical picture that is consistent with PID. Patients with PID may present with lower abdominal or pelvic pain, vaginal discharge, nausea, vomiting; and they may have dysuria and dyspareunia. Patients may have a history of multiple sexual partners and a lack of contraception use. Typical physical examination findings include lower abdominal tenderness. Rebound and guarding may be seen in more severe disease. In addition, pelvic exams will reveal adnexal, uterine or cervical motion tenderness. A friable cervix with mucopurulent discharge may be seen on pelvic exam. (Thick white discharge on speculum examination is suggestive of candidal vaginitis, not PID, which is the likely diagnosis in this patient and typically presents with mucopurulent discharge)

Question 400

Epidemiology of simple and complex ovarian cysts in post-menarchal adolescent females?

Answer 400

Simple and complex ovarian cysts are relatively common in post-menarchal adolescent females (Simple cysts result from the failure of a maturing follicle to ovulate and involute)

Question 401

Ovarian cysts presentation

Answer 401

While often asymptomatic, ovarian cysts can cause pelvic pain, irregular menses or (when large) reports of pelvic "heaviness," urinary frequency, and constipation.

Question 402

Complications of ovarian cysts include

Answer 402

cyst rupture with varying severity of intraperitoneal bleeding and ovarian torsion US is the first line of diagnosis (Clinicians should maintain a high index of suspicion for ovarian torsion when evaluating an adolescent female with acute, severe lower abdominal pain with nausea/vomiting particularly if there is a history of ovarian cysts or an ovarian mass.)

Question 403

All sexually active women younger than 25 years should be tested for

Answer 403

gonorrhea and chlamydia every year (This can be done with urine-based or vaginal swab tests as an alternative to cervical swabs)

Question 404

Key considerations for treating gonnorhea

Answer 404

Treat gonorrhea with dual therapy in order to decrease development of antibiotic resistance and treat concurrent chlamydial infections

Question 405

In what media does Neisseria gonorrhea grow?

Answer 405

Thayer-Martin in CO2-enriched environment

Question 406

Polymenorrhea definition

Answer 406

frequent menstrual bleeding (frequency, 21 days or less) (refers to a menstrual interval of less than 21 days)

Question 407

Menorrhagia definition

Answer 407

prolonged or excessive uterine bleeding that occurs at regular intervals (the loss of 80 mL or more of blood that lasts for more than 7 days)

Question 408

A 15-year-old girl is brought to the emergency department with intermittent lower abdominal pain. The patient woke up this morning with intermittent, sharp pain in the left lower quadrant that radiates to the lower back. The pain episodes are associated with nausea and vomiting and spontaneously resolve after a few minutes. She has no nausea or vomiting between episodes and no urinary symptoms, vaginal bleeding, or abnormal vaginal discharge. The patient has no chronic medical conditions and takes no daily medications. Her last menstrual period was 2 weeks ago, and she is not sexually active. Temperature is 37.2 C (99 F), blood pressure is 130/84 mm Hg, pulse is 118/min, and respirations are 20/min. On examination, the patient appears comfortable and has mild tenderness to palpation in the left lower quadrant. Urine pregnancy test is negative. Pelvic ultrasound shows a 5-cm left ovarian mass with normal ovarian arterial and venous blood flow. After the ultrasound, the patient has another episode of severe pain with nausea when walking back to her room from the restroom. On reevaluation, she is in acute distress and has severe, constant tenderness to palpation in the left lower quadrant. Which of the following is the best next step in management of this patient?

Answer 408

Diagnostic laparoscopy Partial ovarian torsion typically presents with intermittent, self-resolving episodes of unilateral pelvic pain due to temporary ovarian vessel occlusion. Patients with intermittent partial torsion can suddenly develop complete torsion, which requires diagnostic laparoscopy.

Question 409

Partial ovarian torsion presentation

Answer 409

Patients classically have nausea, vomiting, and intermittent pain that self-resolves (ie, no symptoms between episodes) as spontaneous adnexal untwisting allows blood flow to return. Therefore, Doppler ultrasound may show normal ovarian arterial and venous blood flow.

Question 410

Complete ovarian torsion, typically triggered by ———, presents with ———. Management is with ———

Answer 410

physical activity (eg, walking) severe, constant, unilateral pelvic pain due to ongoing ovarian ischemia diagnostic laparoscopy for manual detorsion of the adnexa and removal of any contributory cysts or masses (oophorectomy may be required if the ovary is necrotic)

Question 411

Treatment of N. gonorrhoeae

Answer 411

IM dose of ceftriaxone If chlamydial infections have not been excluded, then additional antibiotics are indicated. Although doxycycline 100 mg BID x 7 days is recommended, for patients who are pregnant or allergic to doxycycline, azithromycin 1 gram orally x1 is also acceptable.

Question 412

Reasons to hospitalize a PID patient include:

Answer 412

-Pregnancy -Previous non-adherence with prescribed medications -High fever or severe illness -Intractable vomiting/inability to tolerate oral medications -Inability to exclude a surgical emergency -Inadequate response on oral therapy within 72 hours -Tubo-ovarian abscess

Question 413

ACOG recommends universal screening of all pregnant people for GBS colonization via rectovaginal swab at

Answer 413

36 0/7 - 37 6/7 weeks unless GBS bacteriuria was detected during the pregnancy or the patient had a previous newborn was infected with GBS

Question 414

For those who test positive for colonization, intrapartum antibiotic prophylaxis with ———should be given unless ———

Answer 414

penicillin or ampicillin a penicillin allergy is reported (First-generation cephalosporins are the alternative for patients reporting a penicillin allergy that is not anaphylaxis. Patients at high-risk for anaphylaxis should receive clindamycin if the GBS is susceptible to clindamycin. If the GBS is not susceptible to clindamycin, vancomycin is recommended)

Question 415

The goal is that GBS antibiotic prophylaxis will begin ——— prior to delivery for optimal protection of the newborn.

Answer 415

at least four hours

Question 416

For patients who are not screened for GBS, antibiotic prophylaxis is recommended for those with certain risk factors such as

Answer 416

- delivery at less than 37 weeks gestation - prolonged rupture of membranes greater than 18 hours -history of GBS positivity in a previous pregnancy

Question 417

A fetus ——— gestation age is neurologically immature and thus is not expected to have a “reactive” FHR. Thus, an NST is not a good test for fetal well-being in this population.

Answer 417

<28 weeks’

Question 418

FHR BTBV The variability ↓ with:

Answer 418

■ Fetal acidemia ■ Fetal asphyxia (Hypoxia with metabolic acidosis) ■ Maternal acidemia ■ Drugs [narcotics, magnesium sulfate (MgSO4), barbiturates, etc.] ■ Acquired or congenital neurologic abnormality

Question 419

Absent FHR BTBV =

Answer 419

Fetal acidosis, and delivery should be expedited.

Question 420

Fetal tachycardia can be caused by

Answer 420

maternal fever or infection and fetal anemia or hypoxia

Question 421

Non-reassuring fetal status with regard to FHR BTBV

Answer 421

Minimal (5 or fewer beats per minute), absent, or marked (greater than 20 beats per minute) variability of the fetal heart rate

Question 422

Reassuring Fetal Status markers include

Answer 422

-Moderate variability (6 to 20 beats per minute). -A subjective report of active fetal movement. -A "reactive" strip showing two heart rate accelerations (of at least 15 seconds with a peak of at least 15 beats per minute above the baseline) in a 20-minute period.

Question 423

Active labor is associated with

Answer 423

strong regular contractions every three to five minutes and a cervical dilation of more than 6 cm in the setting of contractions (The fetal heart tracing does not impact the diagnosis of active labor)

Question 424

First stage of labor (latent and active) defined by

Answer 424

Latent phase: regular contractions have started, but the cervix is less than 6 cm dilated Active phase: begins when 6 cm dilated; ends when fully dilated

Question 425

Second stage of labor defined by

Answer 425

begins at full dilation; ends when the baby is delivered

Question 426

Third stage of labor defined by

Answer 426

begins with the birth of the baby; ends with delivery of the placenta

Question 427

Patients with CIN 3 require what tx?

Answer 427

cervical conization (or LEEP), which is a diagnostic (ie, evaluation for invasive cancer) and therapeutic (ie, excision of dysplastic lesion) procedure. The excised specimen is assessed for depth of invasion and surgical margins (ie, whether all dysplasia was removed).

Question 428

After cervical conization (or LEEP), in patients without invasive cancer, management is based on surgical margins: Patients with positive surgical margins

Answer 428

have residual cervical dysplasia that can progress to cancer. Therefore, these patients require additional surgical excision with either repeat conization (if future fertility is desired) or hysterectomy (if no future fertility is desired)

Question 429

After cervical conization (or LEEP), in patients without invasive cancer, management is based on surgical margins: Patients with negative surgical margins

Answer 429

have no evidence of residual dysplasia. Because these patients have persistent HPV infection that has caused prior high-grade disease, they are at high risk for recurrent cervical dysplasia and cancer. Therefore, they require more frequent cervical cancer screenings with HPV-based testing (eg, primary HPV testing [without cervical cytology] or co-testing [with cervical cytology]) at 6 months postprocedure. If the result is HPV-negative, patients require annual HPV-based testing for the next 3 years

Question 430

Uterine fibroids are a common cause of ——— in ———, typically causing ———

Answer 430

abnormal uterine bleeding premenopausal women heavy, prolonged menses

Question 431

Fibroids typically ——— after menopause

Answer 431

decrease in size and become asymptomatic

Question 432

PMB is a common presenting finding for ——— (particularly in ———)

Answer 432

endometrial hyperplasia or cancer (all patients with PMB require endometrial evaluation) older women with obesity

Question 433

Endometrial evaluation for PMB:

Answer 433

with either transvaginal ultrasound or endometrial biopsy. Endometrial biopsy can supply a histologic diagnosis, but it is an invasive and uncomfortable procedure. Therefore, PMB can also be evaluated initially with transvaginal ultrasound. Patients with an endometrial thickness ≤4 mm on ultrasound have a low likelihood of endometrial cancer and require no additional evaluation. In contrast, patients with an endometrial thickness >4 mm require an endometrial biopsy to assess for endometrial hyperplasia or cancer.

Question 434

Patients with endometrial hyperplasia managed with

Answer 434

medically (eg, progestin) or surgically (eg, hysterectomy)

Question 435

Patients with endometrial cancer are typically managed with

Answer 435

surgically

Question 436

——— are conditions that should not cause PMB, unless the patient is using MHT.

Answer 436

Uterine fibroids and adenomyosis

Question 437

——— should be considered in postmenopausal patients with rapidly enlarging fibroids and bleeding, although the incidence of this is quite small.

Answer 437

Leiomyosarcoma

Question 438

Nursing mothers rarely ovulate within the first ——— weeks after delivery. Non-nursing mothers typically ovulate ——— weeks after delivery.

Answer 438

10 6-8

Question 439

——— (3 infections) are excreted in breast milk.

Answer 439

CMV, HBV, and HIV

Question 440

Breast engorgement commonly occurs

Answer 440

3-5 days after delivery, when colostrum is replaced by milk, resulting in high milk production volumes (exacerbated by a physiologic increase in interstitial edema from decreasing progesterone levels after delivery) (Engorgement may also occur during times when milk accumulation exceeds drainage (eg, breastfeeding weaning))

Question 441

Presentation breast engorgement:

Answer 441

bilateral symmetric breast fullness with diffuse tenderness, warmth, and erythema (no fever)

Question 442

Tx breast engorgement:

Answer 442

Cool compresses, acetaminophen, and nonsteroidal anti-inflammatory drugs may be used for symptom control Patients should experience improvement as breastfeeding or regular pumping is established

Question 443

Presentation of lactational mastitis

Answer 443

Often have flulike symptoms (eg, fever, myalgias) and unilateral breast pain with a focal area of erythema and tenderness

Question 444

Galactocele and plugged ducts present as

Answer 444

palpable mass Galactocele- subareolar, mobile, well-circumscribed, non tender mass, no fever Plugged duct- focal tenderness and firmness and erythema; no fever

Question 445

Breast abscesses presentation

Answer 445

Appear like mastitis and an associated area of fluctuance and axillary lymphadenopathy

Question 446

Mammary candidosis presents with

Answer 446

unilateral, stabbing breast pain that is out of proportion to examination and have associated scaling of the skin on the nipple of the affected breast

Question 447

Components biophysical profile

Answer 447

Question 448

Pregnancies at ≥41 weeks gestation are at increased risk of ———, which can lead to what relative to NST finding

Answer 448

stillbirth In these pregnancies, placental aging leads to decreased placental function, which limits fetal perfusion during contractions and induces intermittent fetal hypoxemia. On nonstress testing, fetal hypoxemia presents as late decelerations, decelerations that gradually nadir after the contraction's peak

Question 449

Progressive placental dysfunction can lead to ———, which causes CNS suppression and potential fetal demise. To maintain CNS function, the hypoxemic fetus preferentially distributes blood to the brain. Decreased perfusion to the ——— results in ———. Decreased blood supply to ———

Answer 449

chronic fetal hypoxemia (ie, uteroplacental insufficiency) kidney decreased urine production and oligohydramnios (single deepest pocket <2 cm) peripheral muscle results in decreased fetal activity (eg, movement, tone) that may be felt by the mother

Question 450

Interstitial cystitis: epidemiology

Answer 450

Question 451

Interstitial cystitis: diagnosis

Answer 451

Question 452

Interstitial cystitis: presentation

Answer 452

Question 453

Interstitial cystitis: treatment

Answer 453

Question 454

Interstitial cystitis: definition and presentation

Answer 454

(also known as painful bladder syndrome) ia chronic, painful bladder condition of uncertain etiology. Patients typically have pain that is exacerbated by bladder filling and relieved by voiding. Symptom onset is typically gradual and worsens over a period of months. Other clinical features include urinary frequency and urgency, chronic pelvic pain, and dyspareunia.

Question 455

Interstitial cystitis: associations

Answer 455

IC typically presents in women age >40 and is associated with other chronic pain conditions (eg, fibromyalgia, endometriosis, irritable bowel syndrome), sexual dysfunction, and psychiatric illness (eg, depression, anxiety)

Question 456

Diagnosis of interstitial cystitis

Answer 456

largely clinical; however, additional laboratory testing—including a urinalysis, postvoid residual, and sexually transmitted infection screening—is performed to exclude other conditions (eg, cystitis, urinary obstruction, malignancy)

Question 457

Management of interstitial cystitis includes

Answer 457

bladder training, fluid management, analgesics, and avoidance of any precipitating agents (eg, caffeine, alcohol, artificial sweeteners)

Question 458

Cystocele present with

Answer 458

Cystocele (bladder prolapse into the anterior vaginal wall) may cause dyspareunia and urinary symptoms (eg, frequency), changes on pelvic examination with Valsalva (ie, prolapse) (cystoceles are common in multiparous women)

Question 459

Pelvic organ prolapse occurs when there is ——— and may be classified according to the location of the herniated pelvic organ ie, (described as occur- ring in the anterior vaginal wall (———), posterior vaginal wall (———), uterus/cervix, or the vaginal vault/vaginal cuff in patients who have undergone a hysterectomy (small bowel———). ———occurs when there is herniation of all three compartments, including uterus, through the vaginal introitus.

Answer 459

descent of one or more aspects of the vaginal walls or uterus, allowing nearby organs to herniate into the vagina cystocele rectocele enterocele Uterine procidentia

Question 460

An overactive bladder presents with

Answer 460

urinary urgency (an intense need to urinate) that can be accompanied by nocturia and frequency (There is no associated dyspareunia or pelvic pain relieved with voiding)

Question 461

A 57-year-old G3P3 patient presents with a sensation of pressure and a bulge in her vagina that is worse at the end of the day. She is healthy and has no medical problems. Her history is significant for three vaginal deliveries proven to 8 lb, and menopause since age 52. What is the next step in the evaluation of this patient?

Answer 461

Take a detailed history of symptoms and perform a complete pelvic exam to assess for POP. Examine the patient in both the supine and standing positions to help determine the severity of the prolapse.

Question 462

Stress Incontinence presents as

Answer 462

Loss of urine (usually small amount) with↑ intra-abdominal pressure (i.e., with coughing, laughing, exercise, other effort or physical exertion)

Question 463

Stress incontinence often caused by

Answer 463

urethral hypermotility and/or intrinsic sphincter deficiency (Urethral hypermobility may occur when there is insufficient support of the urethra and bladder neck by the pelvic floor musculature and vaginal connective tissue, resulting in the loss of ability of these organs to close completely against the anterior vaginal wall. Increases in intraabdominal pressure results in the urethra failing to close properly, leading to stress incontinence. Intrinsic sphincter deficiency occurs when there is a loss of the normal intrinsic urethral mucosal and muscular tone that usually keeps the urethra closed.)

Question 464

A 52-year-old G4P4 patient reports sudden urgency to void followed by loss of urine before she makes it to the bathroom. The urge is not precipitated by laughing or coughing, and she does not leak constantly throughout the day. What is the most likely underlying cause of her incontinence?

Answer 464

This patient is most likely to have urge incontinence that is caused by unopposed detrusor muscle contraction.

Question 465

Presentation of urge incontinence

Answer 465

Sudden feeling of urgency followed by involuntary leakage of urine (can be small or large volume loss). Often accompanied with urinary frequency and nocturia.

Question 466

Caused by of urge incontinence

Answer 466

unopposed detrusor contraction. Also called “overactive bladder.”

Question 467

Mixed Incontinence: definition

Answer 467

Describes patients with a combination of stress and urge incontinence

Question 468

Overflow Incontinence presents with

Answer 468

Constant dribbling +/– continuous leakage with inability to completely empty the bladder

Question 469

Overflow Incontinence caused by

Answer 469

detrusor underactivity (due to a neuropathy) or urethral/bladder outlet obstruction

Question 470

Incontinence that presents as continuous urinary leakage may be due to ———. This can occur as a result of:

Answer 470

a fistula ■ Prior pelvic surgery ■ Obstetric trauma ■ Radiation

Question 471

A urethral diverticulum is an ——— and can cause ———

Answer 471

abnormal outpouching of the urethra a tender anterior vaginal mass, purulent urethral discharge, increased pain with voiding, urethral tenderness, urinary frequency, and dyspareunia

Question 472

Describe the steps and interpretation of the q tip test

Answer 472

A cotton swab is placed in the urethra. The change in angle between the Q-tip and the woman’s body is measured upon straining. Normal upward change is <30 degrees, and a positive test is one with >30-degree change. A positive test indicates urethral hypermobility

Question 473

Cystometry provides measurements of (Measurements include post residual volume, volumes at which an urge to void occurs, bladder compliance, flow rates, and capacity. Diagnoses: Stress, urge, and overflow incontinence.)

Answer 473

the relationship of pressure and volume in the bladder

Question 474

Overflow incontinence treatment

Answer 474

Due to obstruction: Relieve obstruction. Due to detrusor underactivity: Treat possible neurological causes—diabetes mellitus or vit b12 deficiency

Question 475

Treatment urge incontinence

Answer 475

Meds, timed voiding, and lifestyle changes: Antimuscarinic agents (↑bladder capacity,↓ urge by blocking release of acetylcholine during bladder filling). Most common side effects are dry mouth and constipation. Mirabegron (beta-3-adrenoreceptor agonist) Timed voiding: Patient is advised to urinate in prescribed hourly intervals before the bladder fills Avoid stimulants and diuretics (i.e., alcohol, coffee, carbonated beverages)

Question 476

Treatment stress incontinence

Answer 476

Kegel exercises strengthen pelvic floor muscles α-adrenergic agonists Topical vaginal estrogen Incontinence pessary Surgical repair (Midurethral slings are considered first-line surgical treatment)

Question 477

A 23-year-old G3P2002 patient at 25 weeks presents to triage with fever, nausea, and vomiting for 1 day. She reports back pain and lower abdominal pain. She has a fever of 101.2°F (38.4°C), clear lungs, and right costovertebral tenderness. Fetal heart rate is reassuring. The monitor shows contractions every 2 minutes. Cervix is closed/ thick/high. Urine dip shows many bacteria, leukocytes, nitrites, and ketones. What is the most likely diagnosis? What is the next step in management?

Answer 477

The clinical presentation is most consistent with pyelonephritis. She should be admitted to the hospital and given IV hydration and IV antibiotics.

Question 478

Major risk of asymptomatic bacteriuria in pregnancy

Answer 478

increased risk for acute pyelonephritis (and subsequent complications, including acute respiratory distress syndrome and preterm labor and delivery)

Question 479

Because of the risks for pyelonephritis in pregnancy, all women require

Answer 479

urine culture screening for asymptomatic bacteriuria at the initial prenatal visit

Question 480

The most common associated pathogen for asymptomatic bacteriuria is

Answer 480

Escherichia coli

Question 481

Treatment of pregnant women with asymptomatic bacteriuria require

Answer 481

antibiotic therapy; first-line antibiotics include fosfomycin and beta-lactam antibiotics (eg, cefpodoxime, amoxicillin-clavulanate). As a test of cure, a repeat urine culture is performed after antibiotic treatment due to the risk for persistent or recurrent bacteriuria

Question 482

Risk factors for abruptio placentae are

Answer 482

conditions that can induce premature separation of the placenta from the uterus, such as maternal abdominal trauma, preeclampsia/HTN, cocaine, prior abruptly placentae

Question 483

Risk factors for cervical insufficiency include

Answer 483

conditions that weaken the structural integrity of the cervix, such as prior cervical trauma (eg, cold knife cone, obstetric trauma) and collagen abnormalities (eg, Ehlers-Danlos syndrome)

Question 484

The most common risk factor for fetal macrosomia (ie, birth weight ≥4.5 kg [9 lb 14 oz]) is

Answer 484

diabetes mellitus

Question 485

Risk factors for intraamniotic infection include

Answer 485

prolonged membrane rupture and protracted labor, which extend the opportunity for normal vaginal flora to ascend into the uterus and cause infection

Question 486

Late-term pregnancy defined as and post-term pregnancy defined

Answer 486

≥41 weeks gestation ≥42 weeks gestation

Question 487

Late- and post-term pregnancies are at risk of

Answer 487

uteroplacental insufficiency and chronic fetal hypoxemia, which cause CNS suppression and intrauterine fetal demise; To prevent this suppression, blood is preferentially distributed to the brain rather than peripheral tissue. This redistribution can be evidenced on US as oligohydramnios (single deepest pocket <2 cm or amniotic fluid index <5 cm) as amniotic fluid is dependent on renal perfusion and urine production. (placental function due to age-related placental changes (eg, infarctions, calcifications) that cause increased placental vascular resistance)

Question 488

Complication of late term pregnancies

Answer 488

Fetus: Macrosomia Dysmaturity syndrome Oligohydramnios Demise Maternal: Caesarian delivery Severe obstetric lacerations Post-partnum hemorrhage

Question 489

Risk factors for late term pregnancies

Answer 489

Nullparity Age > 34 Obesity Fetal anomalies (anencephaly) Prior post-term pregnancies

Question 490

Management of post-term pregnancies

Answer 490

Frequent fetal monitoring (NST) Delivery prior to 43 weeks

Question 491

Because the risk of ——— increases with gestational age, patients with late- and post-term pregnancies require frequent fetal monitoring (eg, ———). Patients with findings suggestive of ———, require ———

Answer 491

uteroplacental insufficiency nonstress test, ultrasound for amniotic fluid volume uteroplacental insufficiency, such as late decelerations or oligohydramnios delivery to prevent intrauterine fetal demise

Question 492

Risk factors for placenta accreta include

Answer 492

prior cesarean delivery (particularly in patients with a placenta previa in the current pregnancy) and prior uterine myomectomy

Question 493

Polyhydramnios (single deepest pocket ≥8 cm or an amniotic fluid index of ≥24 cm) is associated with

Answer 493

congenital fetal malformations (eg, esophageal atresia, anencephaly) maternal diabetes mellitus

Question 494

Risk factors for preeclampsia include

Answer 494

extremes of maternal age (eg, <18, >40) nulliparity chronic hypertension diabetes mellitus renal disease

Question 495

In the brain, preeclampsia increases the risk of

Answer 495

ischemic and hemorrhagic stroke

Question 496

Treatment of pre-eclampsia with severe features

Answer 496

Antihypertensive therapy (eg, IV labetalol, IV hydralazine) Treatment of preeclampsia with severe features is with delivery because removal of the placenta is typically curative

Question 497

Management preeclampsia

Answer 497

<37 weeks and no severe features: expectant >= 37 weeks or >=34 weeks with severe features: delivery Severe range BP: IV labetolol, IV hydralazine, PO nifedipine Seizure prophylaxis: magnesium sulfate

Question 498

RFs for chlamydia and gonorrhea in women

Answer 498

Age <25 High risk sexual behavior

Question 499

Manifestations for chlamydia and gonorrhea in women

Answer 499

Asymptomatic (most common) Cervicitis Urethritis Periherpatitis (futz high Curtis syndrome)

Question 500

Dx of for chlamydia and gonorrhea in women

Answer 500

Nucleus acid amplification test

Question 501

Tx of for chlamydia and gonorrhea in women

Answer 501

Empiric: ceftriaxone and doxycycline (azithromycin in pregnancy) Confirmed chlamydia: doxycycline (azithromycin in pregnancy) Confirmed gonorrhea: Ceftriaxone

Question 502

Complications for chlamydia and gonorrhea in women

Answer 502

PID Ectopic pregnancy Infertility Pharyngitis

Question 503

Presentation acute cervicitis caused by Chlamydia trachomatis or Neisseria gonorrhoeae

Answer 503

mucopurulent cervical discharge and a friable cervix (ie, bleeding on contact); some patients also have concomitant urethritis (eg, dysuria, positive leukocyte esterase with negative nitrites) due to the proximity of the urethra to the vagina. (CMT a sign of ascending infection (ie, PID), may be absent with low bacterial count or in early infection)

Question 504

Gonorrhea is often asymptomatic and therefore may go untreated, causing complications of

Answer 504

adhesions/inflammation such as ectopic pregnancy, chronic pelvic pain, and infertility

Question 505

A 19-year-old G2P2 patient presents with known exposure to gonorrhea 7 days prior. The patient reports an ↑ in vaginal discharge for the past day, but denies any other symptoms. On physical exam, you notice minimal vaginal discharge. You obtain a nucleic acid amplification test (NAAT) for gonorrhea. What is the next step?

Answer 505

Treat the patient empirically. Since the patient notes to a recent exposure to gonorrhea, do not wait for the result to come back. In female patients, asymptomatic infection is common and symptoms may not begin until 7–21 days after exposure.

Question 506

There is a ———% chance of transmission after one exposure to gonorrhea

Answer 506

50–90

Question 507

Patients diagnosed with any STI are at an increased risk for ——— and should be tested.

Answer 507

HIV

Question 508

For patients with acute cervicitis, ——— testing for C trachomatis and N gonorrhoeae is recommended.

Answer 508

nucleic acid amplification (However, empiric treatment prior to the return of results is needed to prevent transmission to sexual partners and to decrease the risk for long-term sequelae (eg, ectopic pregnancy, infertility)).

Question 509

First-line empiric treatment for N gonorrhoeae

Answer 509

dual therapy with ceftriaxone plus doxycycline (Ceftriaxone covers N gonorrhoeae, a gram-negative diplococcus, and doxycycline covers C trachomatis, an atypical organism.)

Question 510

During pregnancy,——— is used in place of ——— (a potential teratogen) for C trachomatis coverage

Answer 510

azithromycin doxycycline

Question 511

Endometrial stripe ——— mm in a patient with PMB should prompt an evaluation for malignancy.

Answer 511

>4–5

Question 512

RFs vaginal cancer

Answer 512

Age >60 Tobacco use HPV infection In utero DES exposure (Clear cell adenocarcinoma only)

Question 513

Clinical features vaginal cancer

Answer 513

Vaginal bleeding Irregular vaginal lesion Malodorous vaginal discharge

Question 514

Vaginal squamous cell carcinoma presents with

Answer 514

Although many women are diagnosed with vaginal cancer on routine screening, those with large, symptomatic lesions often have vaginal bleeding and malodorous vaginal discharge. (Additional clinical features that suggest metastatic disease include pelvic pain, urinary symptoms (eg, hematuria), and bulk symptoms (eg, constipation))

Question 515

Vaginal squamous cell carcinoma typically appear as

Answer 515

an irregular plaque or ulcer in the upper third of the posterior vagina

Question 516

Cervical cancer and vaginal cancer results from

Answer 516

persistent HPV infection with high-risk types 16 and 18 (Chronic tobacco use decreases the immune response and prevents viral clearing)

Question 517

Reiter Syndrome (due to chlamydial infection):

Answer 517

Classic triad of conjunctivitis, urethritis, and reactive arthritis: Can’t see, can’t pee, can’t climb a tree.

Question 518

Diethylstilbestrol exposure in utero can cause

Answer 518

infertility (due to anatomic defects) vaginal clear cell adenocarcinoma

Question 519

Patients with Lynch syndrome (hereditary nonpolyposis colorectal cancer, or HNPCC) have a 40–60% lifetime risk of developing

Answer 519

endometrial cancer, which is equal to their risk of developing colorectal cancer

Question 520

Any factor that lowers the level or time of exposure to ——— ↓ the risk of endometrial cancer.

Answer 520

estrogen

Question 521

RFs for endometrial cancer

Answer 521

Question 522

Use ——— rather than ——- for pregnant patients with chlamydia. (As the latter may cause ———)

Answer 522

azithromycin Doxycycline discoloration of the fetal teeth

Question 523

Clinical features of AFLP

Answer 523

Nausea, vomiting RUQ/epigastric Pain Fulminant liver failure

Question 524

Management of AFLP

Answer 524

Immediate delivery

Question 525

Lab finding in AFLP

Answer 525

Elevated bilirubin Elevated aminotransferases (2-3x normal) Thrombocytopenia DIC Profound hypoglycemia

Question 526

Acute fatty liver of pregnancy usually develops in the _____ trimester, particularly in patients with _____ .

Answer 526

third multiple gestation

Question 527

AFLP presents with

Answer 527

hepatic inflammation (eg, epigastric/right upper quadrant pain, leukocytosis, elevated aminotransferases) and subsequent fulminant liver failure (eg, scleral icterus, hyperbilirubinemia, profound hypoglycemia) (As AFLP progresses, patients can develop multiorgan system failure, including DIC (eg, hemolytic anemia, thrombocytopenia) and acute kidney injury (from hepatorenal syndrome))

Question 528

Centrofacial hyperpigmentation that spares the nasolabial folds in pregnancy

Answer 528

Melasma, a common benign condition in pregnancy (This is likely induced by estrogen and progesterone effects on melanocytes, causing increased melanin accumulation.  It typically fades postpartum, although some hyperpigmentation may persist.

Question 529

Define polymorphic eruption of pregnancy (also known as pruritic urticarial papules and plaques of pregnancy [PUPPP])

Answer 529

May be triggered by the skin stretching over the enlarging gravid uterus that causes inflammation and pruritus within abdominal striae.  It is a benign self-limited condition that resolves postpartum.

Question 530

Increasing upper lip hair in pregnancy?

Answer 530

Normal. Due to increased circulating androgens (placental and ovarian), causing thickened terminal hair growth.  In addition, scalp hair spends more time in the anagen growth phase, causing decreased hair loss.  Hair loss occurs postpartum due to a large proportion of hair in the resting telogen phase (ie, telogen effluvium); however, terminal hairs may be permanent.

Question 531

Spider angiomas in pregnancy?

Answer 531

Normal, benign, erythematous lesions that blanch with pressure.  They typically resolve postpartum.

Question 532

Define labial adhesions

Answer 532

Thin, fused labia minora (Labial adhesions can be partial (involving a portion of the labia) or complete)

Question 533

Labial adhesions most commonly seen in

Answer 533

Prepubertal girls due to low estrogen production (Inflammation from poor hygiene, infection (eg, vaginitis), irritation (eg, diaper rash), or trauma (eg, straddle injury) also contributes to the development of adhesions)

Question 534

Sxs of labial adhesions

Answer 534

Partial adhesions often asymptomatic (Some individuals may experience vaginal pain or pulling.  Adhesions covering the urethral meatus can also cause an abnormal urinary stream and an increased risk for recurrent UTIs due to urine accumulation)

Question 535

Tx labial adhesions

Answer 535

Mild, asymptomatic adhesions require no treatment. Topical estrogen is first-line therapy for those with symptoms.

Question 536

Candida vulvovaginitis presents with a

Answer 536

Beefy-red rash on the vulva as well as vaginal pruritis and discharge

Question 537

Contact dermatitis presents with

Answer 537

a pruritic, erythematous rash

Question 538

Lichen sclerosus is characterized by

Answer 538

hypopigmented labial lesions

Question 539

Pinworm infection typically presents in ______ with ______

Answer 539

school-age children perianal itching, particularly at night

Question 540

Urethral prolapse presents in ______ with _______

Answer 540

prepubertal girls inflamed, friable tissue in a donut shape at the urethral meatus

Question 541

A 60-year-old G1P1 patient reports vulvar itching. She has a history of lichen sclerosus that previously responded well to topical high potency steroids. On exam, she has a raised, white lesion on her vulva. What is the best next step in the management of this patient? Is this patient at ↑ risk for malignancy? What microscopic changes contribute to the white appearance?

Answer 541

The next step in diagnosis is a punch biopsy. An ↑ risk of vulvar carcinoma is associated with lichen sclerosus (LS), and lichen planus (LP). The white appearance is secondary to lichenification.

Question 542

lichen sclerosus (LS) carries ↑ risk of

Answer 542

vulvar squamous cell cancers

Question 543

Lichen simplex chronicus (LSC) is a skin condition caused by ——— ; both a primary cause of ——— and a secondary complication of a ———.

Answer 543

chronic itching and scratching vulvar itching Any inflammatory vulvar disorder

Question 544

Up to 70% of patients with lichen planus will have ——— involvement

Answer 544

oral

Question 545

Disorders of the active phase of labor include: protraction and arrest. Define protraction

Answer 545

Cervical change slower than expected, with or without inadequate contractions

Question 546

Disorders of the active phase of labor include: protraction and arrest. Define arrest

Answer 546

No cervical change for >=4 hours with adequate contractions Or No cervical change for >=6 hours with inadequate contractions

Question 547

Treatment for active phase of labor protraction

Answer 547

oxytocin

Question 548

Treatment for active phase of labor arrest

Answer 548

Caesarean Delivery

Question 549

The first stage of labor begins with _____ and ends when _____.  It consists of a latent phase involving gradual cervical dilation and an active phase with rapid dilation.  The transition between the latent and active phase occurs _____.

Answer 549

the onset of regular contractions the cervix is 10 cm dilated at 6 cm dilation

Question 550

The active phase of labor (6-10 cm cervical dilation) has an expected, predictable rate of cervical dilation of

Answer 550

≥1 cm every 2 hours

Question 551

Causes of active phase arrest include

Answer 551

uterine (eg, inadequate contractions), fetal (eg, malposition, macrosomia), or pelvic (eg, deformity or fracture)

Question 552

Adequate contractions

Answer 552

200-250 MVUs

Question 553

Serotypes L1–L3 of C. trachomatis cause ———, most commonly found in ——— areas.

Answer 553

lymphogranuloma venereum tropical

Question 554

Lymphogranuloma venereum presentation

Answer 554

■ Primary lesion: Painless papule on genitals. ■ Secondary stage: Inguinal lymphadenitis with fever, malaise, and loss of appetite. ■ Tertiary stage: Rectovaginal fistulas, rectal strictures.

Question 555

Amnioinfusion is performed using an intrauterine pressure catheter and is indicated for 

Answer 555

fetal heart rate tracing abnormalities (ie, variable decelerations)

Question 556

Indication for an operative vaginal delivery (eg, vacuum-assisted vaginal delivery)

Answer 556

during the second stage of labor (10 cm dilation until fetal delivery) to expedite delivery for category III tracings or maternal exhaustion

Question 557

Oxytocin augments labor by ——— and is used for patients who ———

Answer 557

increasing contraction frequency and strength meet criteria for labor protraction (ie, cervical dilation rate <1 cm/2 hr) but not for those who meet criteria for labor arrest

Question 558

Evaluation for female factor infertility often includes hysterosalpingography (HSG) to

Answer 558

identify genital tract anomalies and fallopian tube patency

Question 559

What are bicornuate or separate uterus, and how are they addressed?

Answer 559

2 unfused uterine horns, types of congenital uterine anomalies Some congenital uterine anomalies, such as a septate uterus, can be surgically corrected to recreate a single, larger uterine cavity

Question 560

Complications of bicornuate or separate uterus

Answer 560

Spontaneous abortion:  Congenital uterine anomalies are commonly associated with absent or abnormal vasculature and diminished uterine blood flow.  Therefore, pregnancies experience decreased placental perfusion and inadequate nutrition, which can cause fetal growth restriction or recurrent pregnancy loss. Preterm labor:  Because it has 2 separate, smaller uterine cavities, a bicornuate or septate uterus cannot expand fully in volume to accommodate a full-term pregnancy.  When the fetus becomes larger than the cavity, uterine overdistension may trigger preterm labor.  Uterine anomalies may also adversely affect the structural integrity of the cervix, increasing the risk for cervical insufficiency and second-trimester pregnancy loss.

Question 561

RFs for pyelonephritis in pregnancy

Answer 561

Asymptomatic bacteriuria Age<20 Diabetes mellitus

Question 562

Most common pathogen with pyelonephritis in pregnancy

Answer 562

E. coli

Question 563

Complications of pyelonephritis in pregnancy

Answer 563

preterm labor low birth weight ARDS

Question 564

Treatment of pyelonephritis in pregnancy

Answer 564

IV antibiotics Supportive care

Question 565

Pregnant women are at increased risk for _____ due to increased urinary stasis, mild immunosuppression, and progesterone-related ureteral dilation. 

Answer 565

acute pyelonephritis

Question 566

Like most patients, pregnant women with pyelonephritis typically present with

Answer 566

nausea, high-grade fever, and flank pain On examination, CVA tenderness (the angle created between the 12th rib and the spine) or flank pain is common due to retroperitoneal inflammation of the kidney. Retroperitoneal inflammation can also extend to the abdominopelvic cavity.  This can cause obstetric symptoms, such as uterine irritability (eg, nonpainful contractions), that can progress to preterm labor (ie, painful contractions with cervical dilation). (Maternal fever and tachycardia also lead to fetal tachycardia (ie, HR >160/min))

Question 567

Severe pyelonephritis can also cause

Answer 567

maternal sepsis, acute respiratory distress syndrome, and fetal compromise (eg, premature birth, low birth weight)

Question 568

Due to the high risk for severe complications, management of acute pyelonephritis in pregnancy is with

Answer 568

hospitalization and empiric intravenous antibiotics (eg, ceftriaxone)

Question 569

Ovarian torsion can present with unilateral abdominal pain, anorexia, and low-grade fever (ie, peritonitis); however, it typically begins as intermittent pain followed by sudden-onset, severe pain consistent with complete vessel occlusion. It is not typically associated with flank tenderness

Answer 569

unilateral abdominal pain, anorexia, and low-grade fever (ie, peritonitis) (typically begins as intermittent pain followed by sudden-onset, severe pain consistent with complete vessel occlusion)

Question 570

Degenerating uterine fibroid in pregnancy can present with

Answer 570

abdominal pain, low-grade fever, and uterine tenderness

Question 571

Intraamniotic infection (IAI) is defined as

Answer 571

maternal fever (without a clear source of infection) plus either maternal or fetal tachycardia, purulent amniotic fluid, or leukocytosis (IAI is a diagnosis of exclusion and common cause of abdominal pain in pregnancy)

Question 572

Acute appendicitis in pregnancy can present with

Answer 572

fever, nausea, anorexia, and right-sided or upper abdominal pain due to uterine displacement of the appendix cephalad; however, appendicitis typically causes peritoneal signs, including rebound or guarding

Question 573

Women age _____ with abnormal uterine bleeding and classic menopausal symptoms (eg, ____) are likely in menopause and require no additional testing.  In contrast, women age _____ with these symptoms require measurement of ______.

Answer 573

≥45 night sweats, insomnia, difficulty concentrating <45 FSH, TSH, and prolactin (eg, FSH (to assess for hypothalamic amenorrhea), TSH (to assess for thyroid disorder), and prolactin (to assess for hyperprolactinemia).

Question 574

A 22-year-old G0 patient presents with a 2-day history of severe, sharp right lower quadrant pain. Her LMP was 13 days ago, and she has no significant medical or surgical history. Her pain is not relieved with ibuprofen. Her vitals show T = 98.2, P = 100, BP 85/60. A pregnancy test is negative. Her hematocrit dropped from 38 to 30%. On exam, her abdomen is soft and tender with rebound and guarding. An ultrasound reveals a normal left ovary and a 4-cm right ovary, with a moderate amount of fluid in the cul-de-sac (pouch of Douglas). What is the most likely diagnosis? What is the best next step in management?

Answer 574

The most likely diagnosis is a ruptured corpus luteal cyst. She recently ovulated, since her period was 2 weeks ago. She has vitals and an exam consistent with an acute abdomen. Given her drop in hematocrit, the fluid in the cul-de-sac is likely blood from the ruptured cyst. She needs surgical treatment with a diagnostic laparoscopy to diagnose and treat.

Question 575

During embryogenesis, sexual development in genotypically male fetuses (46,XY) occurs due to _____ production

Answer 575

testicular hormone

Question 576

The testes produce testosterone, which promotes development of

Answer 576

the male internal genitalia (eg, vas deferens, epididymis)

Question 577

Testosterone is also converted to _____ (via ______), which promotes development of

Answer 577

dihydrotestosterone (DHT) 5-alpha reductase the male external genitalia (eg, penis) and prostate

Question 578

Patients with 5-alpha reductase deficiency are unable to convert _____; therefore, they have

Answer 578

testosterone to DHT undescended testes (eg, bilateral labial masses), have no male external genitalia development, and appear phenotypically female at birth At puberty, increased testosterone levels cause virilization of phenotypically female patients, which can manifest as nodulocystic acne and clitoromegaly (ie, clitoris protruding from the clitoral hood).  Additional features of virilization include voice deepening and increased muscle mass.  The testosterone levels at puberty are at the normal male range; therefore, patients develop additional normal secondary sexual characteristics (eg, axillary and pubic hair).  Patients have no breast development because testosterone binds to the breast androgen receptor and inhibits breast tissue proliferation. 

Question 579

Diagnosis of 5-alpha reductase deficiency in adolescents and adults is based on an

Answer 579

elevated testosterone/DHT ratio (Management is dependent on age and gender identity)

Question 580

Patients with androgen insensitivity syndrome (AIS) have

Answer 580

peripheral testosterone resistance due to a defective androgen receptor

Question 581

In contrast to patients with 5-alpha reductase deficiency, patients with androgen insensitivity syndrome (AIS) have

Answer 581

No virilization in adolescence (ie, clitoromegaly), and they lack axillary and pubic hair development.  Patients with AIS also have breast development at puberty due to aromatization of testosterone to estrogen and because breast tissue proliferation is not inhibited by a defective androgen receptor.

Question 582

Ovarian hyperthecosis can present in women with

Answer 582

virilization, patients are typically postmenopausal and have bilaterally enlarged ovaries

Question 583

Sertoli-Leydig cell tumors are

Answer 583

testosterone-producing ovarian tumors that can result in virilization, patients have a unilateral, solid adnexal mass

Question 584

Pathogenesis of 5 alpha reductive deficiency

Answer 584

Question 585

Presentation of 5 alpha reductase deficiency

Answer 585

Question 586

To prevent alloimmunization, anti-D immune globulin is administered

Answer 586

at 28 weeks gestation and repeated within 72 hours of delivery

Question 587

——— is commonly used to determine the dose of anti-D immune globulin. 

Answer 587

The Kleihauer-Betke (KB) test: Red blood cells from the maternal circulation are fixed on a slide.  The slide is exposed to an acidic solution and adult hemoglobin lyses, leaving "ghost" cells.  The dose of anti-D immune globulin is calculated from the percentage of remaining fetal hemoglobin.

Question 588

A ——— block can provide pain relief at the time of a vaginal delivery.

Answer 588

pudendal nerve

Question 589

Bartholin gland blockage causes a cyst or abscess. Presentation difference?

Answer 589

Most often: Cysts: Asymptomatic Abscesses: Painful

Question 590

Vulvar lichen planus is a chronic inflammatory condition that typically occurs in _____. 

Answer 590

postmenopausal women

Question 591

The most common type of vulvar lichen planus is the _____ variant, in which chronic inflammation causes _____.

Answer 591

erosive desquamation and erosion of mucosal surfaces, including the vulva, vagina, and oral cavity

Question 592

Clinical features of erosive lichen planus include:

Answer 592

Glazed, brightly erythematous vulvar erosions with a border of serpentine-appearing, white striae (ie, Wickham striae) that typically cause vulvar pain, pruritus, and dyspareunia. Acute vaginal inflammation that causes friable vaginal mucosa and a serosanguinous vaginal discharge; chronic inflammation can eventually result in stenosis of the vaginal introitus. Lacelike, reticular erosions on the gingivae and palate that cause painful oral ulcers and plaque formations on the tongue.

Question 593

Diagnosis of erosive lichen planus may be made clinically but should be confirmed with a

Answer 593

vulvar punch biopsy because the clinical features of lichen planus may overlap with those of vulvar cancer (Patients with lichen planus require evaluation of all mucosal surfaces because erosions may occur in the absence of other symptoms)

Question 594

First-line treatment is with

Answer 594

high-potency topical corticosteroids

Question 595

Vulvovaginal candidiasis can present with

Answer 595

Vulvovaginal pruritus and erythema, with a thick, white vaginal discharge; some patients (eg, immunosuppressed) can have accompanying oropharyngeal candidiasis (white oral plaques)

Question 596

Lichen sclerosus can present with

Answer 596

Vulvar pruritus and white vulvar plaques with associated erosions (typically have no vaginal involvement)

Question 597

Clinical features of vulvar lichen planus

Answer 597

- Women aged 50-60 - Vulvar pain or pruitis - Dyspareunia - Erosive variant (most common): erosive, glazed lesions with white border; vaginal involvement with or without stenosis; associated oral lesions -Papulosquamos variant: Small pruritic papules with purple hue

Question 598

Diagnosis of vulvar lichen planus

Answer 598

Vulvar biopsy

Question 599

Treatment of vulvar lichen planus

Answer 599

High-potency topical corticosteroids

Question 600

The ovarian stroma, which is primarily composed of _____ cells, produces the ______. 

Answer 600

granulosa ovarian estrogen supply

Question 601

Granulosa cells convert _____ and secrete ______; therefore, uncontrolled proliferation of these cells, as seen in a granulosa cell tumor, results in ______.

Answer 601

testosterone to estradiol (via aromatase) inhibin (which typically inhibits FSH) high estradiol and inhibin levels

Question 602

Women with an adult subtype granulosa cell tumor have _____ exposure that can result in ______.  Additional clinical features may include _____. 

Answer 602

chronic, unopposed estrogen endometrial hyperplasia or cancer (eg, postmenopausal bleeding) breast tenderness and mass-effect symptoms (eg, abdominal distension, ovarian torsion)

Question 603

Embryonal carcinoma is a type of ovarian germ cell tumor that occurs typically in _____.  Embryonal carcinoma secretes _____.

Answer 603

young women alpha-fetoprotein and hCG

Question 604

Mature teratomas (dermoid cysts) are benign germ cell tumors that are more common in _____.  Mature teratomas can secrete ____.

Answer 604

younger women (age 10-30) thyroid hormone (eg, struma ovarii)

Question 605

C

Question 606

Yolk sac tumors are germ cell tumors that are more common in ____ and secrete _____.  Patients typically present with ______.

Answer 606

young women alpha-fetoprotein acute onset of pelvic pain (because yolk sac tumors grow rapidly)

Question 607

Pathogenesis granulosa cell tumors

Answer 607

Sex cord-stromal tumor Increased estradiol and inhibin

Question 608

Clinical features of granulosa cell tumor

Answer 608

Complex ovarian mass Juvenile subtype: Precocious puberty Adult subtype: Postmenopausal bleeding, abnormal uterine bleeding, breast tenderness

Question 609

Histopathology of granulosa cell tumor

Answer 609

Call-exner bodies (cells in a rosette pattern)

Question 610

Mangement of granulosa cell tumor

Answer 610

Endometrial biopsy (endometrial cancer) Surgery (tumor staging)

Question 611

Vulvar lichen sclerosus is a chronic inflammatory condition that causes ——— in ——— populations. 

Answer 611

thinning of the vulvar skin hypoestrogenic (such as premenarchal girls and postmenopausal women)

Question 612

Presentation lichen sclerosus

Answer 612

Thin, white vulvar lesions and changes in vulvar architecture (eg, adherence of the labia at the midline).  These lesions are chronically inflamed and can result in perianal and vulvar pruritus, at times so severe that it awakens affected individuals from sleep.  Excessive scratching can result in excoriations, lichenification (ie, thickened skin), and edema of the labia.  Lichenification of the perianal region can result in anal fissures and constipation.

Question 613

Recommended evaluation associated with lichen sclerosus

Answer 613

Although biopsy is recommended in adults to exclude an underlying malignancy (eg, vulvar cancer), children have no associated malignancy risk and can be diagnosed clinically. 

Question 614

First-line treatment for lichen sclerosus for adults and children:

Answer 614

superpotent topical corticosteroids (eg, clobetasol)

Question 615

Streptococcal dermatitis typically occurs as a superinfection in patients with a constant irritant (eg, bathing suit) and can cause perianal pruritis and anal fissures.  However, patients have a bright, erythematous perianal rash with sharply demarcated borders rather than thin, white skin.

Question 616

Colposcopy:

Answer 616

Magnified view of the cervix, vagina, and vulva

Question 617

Epidemiology of lichen sclerosus

Answer 617

Prepubertal and perimenopausal or postmenopausal women

Question 618

Clinical features of lichen sclerosus

Answer 618

- Thin white wrinkled skin over labia majora/minors, strophic changes that may extend over perineum and around anus - Excoriations, erosions, fissures from severe prutitis - Dysuria, dyspareunia, painful defecation

Question 619

Workup of lichen sclerosus

Answer 619

Punch biopsy of adult onset lesions to exclude malignancy

Question 620

Treatment of lichen sclerosus

Answer 620

Superpotent corticosteroid ointment

Question 621

Most hysterectomies start by ligation and transection of the

Answer 621

round ligament

Question 622

Oligohydraminos (AFI <5cm) causes:

Answer 622

Uteroplacental insufficiency Renal anomalies NSAIDs Preeclampsia Abruptio placentae

Question 623

Oligohydraminos (AFI <5cm) complications:

Answer 623

Preterm delivery Cord compression Meconium aspiration

Question 624

Polyhydramnios (AFI >=24cm) causes:

Answer 624

DM Multiple gestations Esophageal/duodenal atresia Ancephaly Congenital infections

Question 625

Polyhydramnios (AFI >=24cm) complications:

Answer 625

Cord prolapse Preterm labor PPROM Fetal malpresentation

Question 626

Fundal height (ie, uterine size) is measured during routine prenatal visits in the second and third trimesters as an indirect assessment of fetal growth and amniotic fluid volume. After——— weeks gestation, fundal height in centimeters should directly correlate to ——— with a small variation (eg, ± ———);

Answer 626

20 gestational age in weeks 2-3 cm

Question 627

A presumptive diagnosis of GDM can be made with a very elevated 50-g 1-hour GTT (eg, ≥ ——— mg/dL) or confirmed with a 100-g 3-hour GTT

Answer 627

200

Question 628

GDM causes a uterine size–greater-than-dates discrepancy due to resulting

Answer 628

fetal macrosomia and polyhydramnios.

Question 629

A uterine size–dates discrepancy requires further evaluation with ——— to measure ———

Answer 629

ultrasound fetal growth and amniotic fluid volume

Question 630

Incorrect pregnancy dating is a common cause of uterine size–dates discrepancies. However, if a patient's pregnancy is dated by ———, this is the most precise method (ie, within 5-7 days) for establishing gestational age

Answer 630

an early first-trimester ultrasound

Question 631

Rh alloimmunization can cause ——— with associated ———

Answer 631

hydrops fetalis polyhydramnios and subsequent uterine enlargement

Question 632

Oral contraceptives (OCs) commonly cause

Answer 632

mild elevation in blood pressure and sometimes can lead to overt hypertension

Question 633

The risk of hypertension with OC use increases with

Answer 633

the duration of OC use those who have a family history of hypertension Those who developed hypertension during a previous pregnancy

Question 634

The CDC recommends against the use of ——— in women with hypertension.

Answer 634

combination estrogen-progestin OCs (In patients whose hypertension is caused by OC use, discontinuation can reduce blood pressure and often corrects the condition. The physician should have a discussion with the patient about the benefit of stopping the OC, the risks of drug continuation, and alternate contraceptive methods.)

Question 635

Weight gain in pregnancy based on BMI

Answer 635

<18.5 - 28-40 lbs 18.5-24.9 - 25-35lbs 25-29.9 - 15-25lbs 30>= - 11-20lbs

Question 636

Substances to avoid in pregnancy

Answer 636

Undercooked fish, meat, eggs High mercury fish Unpasteurized dairy products High caffeine intake (moderate ok) (Clean raw fruits and veggies)

Question 637

Multiple sclerosis, an autoimmune inflammatory demyelinating disease of the CNS that typically presents in ———. ——— often precedes the development of focal neurologic findings. There is an increased risk of both the initial presentation and subsequent relapses in the ——— An ——— should be obtained, and would show:

Answer 637

young adults, especially women of child-bearing age Extreme fatigue unrelated to activity levels early postpartum period. (Although pregnancy is protective for multiple sclerosis) MRI of the brain and spinal cord Typically, multiple, scattered, ovoid lesions are seen in the periventricular regions and the spinal cord. Imaging findings can often confirm dissemination in space (multiple CNS locations) and time (age of lesions), which are required to confirm a diagnosis of MS

Question 638

Mullerian agenesis pathogenesis

Answer 638

Mullerian system defect Abnormal development of uterus, cervix, and upper third of vagina

Question 639

Clinical features of Mullerian agenesis

Answer 639

Primary amenorrhea Normal female external genitalia Blind vaginal pouch Absent or rudimentary uterus Bilateral functional ovaries (normal fsh)

Question 640

Management Mullerian agenesis

Answer 640

Evaluate for renal tract abnormalities (renal ultrasonography) Vaginal dilation (surgical or nonsurgical)

Question 641

Presentation of müllerian agenesis (Mayer-Rokitansky-Küster-Hauser syndrome)

Answer 641

primary amenorrhea, normal secondary sexual characteristics, and absent uterus (Paramesonephric duct development does not affect ovarian development; therefore, patients have normal estrogen levels and normal secondary sexual characteristics (eg, breasts, normal stature))

Question 642

Mullerian agenesis due to

Answer 642

the failure of paramesonephric duct development (paramesonephric (Müller) ducts develop into the uterus, cervix, and upper third of the vagina. Patients with müllerian agenesis do not develop these structures, so amenorrhea is typically the presenting symptom.) (The lower two-thirds of the vagina and the external female genitalia develop from different precursors (ie, urogenital sinus and genital tubercle, respectively); therefore, patients with müllerian agenesis have the lower two-thirds of the vagina (ie, blind vaginal pouch, vaginal dimple) and normal female external genitalia)

Question 643

GnRH deficiency would present with

Answer 643

primary amenorrhea and lack of secondary sexual characteristics (low GnRH causes a low estrogen level)

Question 644

Androgen insensitivity syndrome presents with

Answer 644

phenotypically female primary amenorrhea due to an absent uterus no pubic or axillary hair due to a defective androgen receptor (complete defect in androgen receptor function)

Question 645

Presentation of 5-alpha reductase deficiency have

Answer 645

female external genitalia and male internal genitalia (ie, undescended testes) until puberty, at which time they undergo virilization (eg, muscle l growth, voice deepening) due to increased levels of testosterone (impaired conversion of testosterone to dihydrotestosterone)

Question 646

Person with developmental failure of the urogenital sinus would have

Answer 646

vaginal dimple or no vaginal opening but have a uterus and fallopian tubes (urogenital sinus forms the lower two-thirds of the vagina)

Question 647

Risk factor ectopic pregnancy

Answer 647

Previous ectopic pregnancy PID Previous pelvic or tubal surgery

Question 648

Clinical features of ectopic pregnancy

Answer 648

Abdominal pain, amenorrhea, vaginal bleeding Hypovolemic shock in ruptured ectopic pregnancy CMT, adenexal, or abdominal tenderness Potentially palpable adenexal mass

Question 649

Diagnosis of ectopic pregnancy

Answer 649

Positive hcg Tranvaginal US revealing adenexal mass, empty uterus

Question 650

Management ectopic pregnancy

Answer 650

Stable: Methotrexate Unstable: surgery

Question 651

Ectopic pregnancy present with

Answer 651

lower abdominal pain vaginal spotting nausea/vomiting An acute increase in pain may occur with tubal rupture, which can lead to hemoperitoneum with blood pooling in the posterior cul-de-sac, resulting in the urge to defecate (due to increased rectal pressure) and potential hemodynamic instability

Question 652

C

Question 653

Risk factors for endometrial hyperplasia

Answer 653

Excess estrogen (obesity, PCOS/chronic anovulation, nullparity, early menarche/late menopause, tamoxifen use)

Question 654

Endometrial hyperplasia/cancer symptoms

Answer 654

Heavy, prolonged, intrermenstrual bleeding or post-menopausal bleeding

Question 655

Endometrial hyperplasia can be due to

Answer 655

chronic unopposed estrogen, which causes uncontrolled endometrial proliferation

Question 656

Endometrial hyperplasia management

Answer 656

In patients who may desire future fertility, initial management is with progestin therapy (eg, progestin-releasing intrauterine device), which counteracts estrogen's effects by inhibiting endometrial proliferation and promoting differentiation. Follow-up is with repeat endometrial biopsy (eg, every 3 months). Patients with stable or improved disease continue progestin therapy, whereas those with progression to cancer typically require hysterectomy

Question 657

Evaluation of endometrial hyperplasia/ cancer

Question 658

Müllerian agenesis (ie, Mayer-Rokitansky-Küster-Hauser syndrome), or abnormal paramesonephric (müllerian) duct development presents with

Answer 658

normal secondary sexual characteristics (eg, breasts, external genitalia), but the uterus and cervix and upper 1/3 vagina are absent The ovaries and external genitalia develop independently of the müllerian duct system; therefore, patients have normal FSH levels (ie, normal ovarian function), normal external genitalia, and the lower two-thirds of the vagina (ie, blind vaginal pouch)

Question 659

Patients with müllerian agenesis should undergo evaluation of the

Answer 659

renal tract (ie, ureters, kidney) with renal ultrasonography (Because of their common embryologic source and synchronous development in the first trimester, internal genital anomalies and renal abnormalities are often concurrent)

Question 660

——— is performed in patients with Turner syndrome to evaluate for ———. Patient has a normal karyotype and FSH level (ie, normal ovarian function), making Turner syndrome unlikely.

Answer 660

Echocardiography cardiac malformations (eg, bicuspid aortic valve, aortic coarctation)

Question 661

——— levels are measured to diagnose 5-alpha reductase deficiency and androgen insensitivity syndrome (AIS).

Answer 661

Dihydrotestosterone and testosterone

Question 662

Presentation 5-alpha reductase deficiency

Answer 662

genotypic males (46,XY) appear phenotypically female until puberty; elevated testosterone levels at puberty then cause virilization (eg, clitoromegaly) and lack of breast development

Question 663

Presentation AIS

Answer 663

genotypic males appear phenotypically female through puberty and have breast development. Those with AIS have no or minimal acne or pubic hair development due to an abnormal androgen receptor.

Question 664

——— levels are measured in patients with primary amenorrhea who have a uterus and a low or normal FSH

Answer 664

TSH and prolactin (MRI of the head is indicated in patients with a low or normal FSH, high prolactin, or visual field defects to evaluate hypothalamic and pituitary causes (eg, sellar mass).)

Question 665

Gestational Thrombocytopenia defined as

Answer 665

Mild isolated (100,000-150,000) No symptoms Diagnosis of exclusion

Question 666

Preeclampsia with severe features/HELLP defined

Answer 666

Moderate-severe thrombocytopenia (<100,000) Hypertension with or without headache and scotomata With or without elevated creatinine, elevated AST/ALT

Question 667

Define gestational thrombocytopenia

Answer 667

benign condition that causes an isolated, mild thrombocytopenia (ie, platelets 100,000-150,000/mm3) Patients are asymptomatic (ie, no bruising, bleeding, or anemia) or have normal physiologic symptoms of pregnancy, such as fatigue, shortness of breath, and symmetric leg swelling

Question 668

Gestational thrombocytopenia management

Answer 668

includes reassurance and observation

Question 669

Fetal dysmaturity syndrome occurs in ——— pregnancies due to ———. Neonates present as

Answer 669

post-term (≥42 weeks gestation) age-related placental changes and resultant uteroplacental insufficiency small for gestational age, have a thin body with loose skin, and have meconium-stained amniotic fluid

Question 670

Types of twins and associated signs on US

Answer 670

Dichorionic, diamniotic - lambda sign (thick intertwin membrane) Monochorionic, diamniotic - t or delta sign (thinner intertwin membrane)

Question 671

Maternal complications with twins

Answer 671

Preeclampsia GDM IDA Hyperemesis Gravidarum

Question 672

Monochorionic, diamniotic twins only are at risk for

Answer 672

Twin twin transfusion syndrome (A serious complication of monochorionic twin gestation in which blood/ intravascular volume is shunted from one twin to another across the shared placenta.)

Question 673

Fetal complications twin getation

Answer 673

Pre-term labor Congenital anomalies IUGR Malpresentation (breech)

Question 674

Monochorionic, monoamniotic twins only are at risk for

Answer 674

Cord entanglement Conjoined twins

Question 675

The most common complication of twin pregnancies is

Answer 675

preterm delivery (ie, <37 weeks gestation)

Question 676

Fetal macrosomia, an estimated fetal weight ≥4,500 g, typically occurs in patients with

Answer 676

gestational diabetes mellitus excessive pregnancy weight gain some syndromes (eg, Beckwith-Wiedemann)

Question 677

Risk factors for placenta accreta include

Answer 677

prior uterine surgery (eg, cesarean delivery, myomectomy), particularly in patients with an associated placenta previa

Question 678

Uterine inversion, an obstetric emergency, occurs when the uterine fundus collapses and turns inside out during delivery of the placenta. Risk factors include

Answer 678

fetal macrosomia uterine anomalies a retained placenta placenta accreta