USMLE
*
Step 2:
Obstetrics and
Gynecology
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Assessment Exam
1. A 38-year-old primigravid woman at 38 weeks’ gesta-tion comes to the physician for a prenatal visit. She has no complaints. Her blood pressure is 140/90 mm Hg. Her booking blood pressure at 8 weeks’ gestation was 110/68 mm Hg and she has no history of hypertension. She has no proteinuria on urine dipstick evaluation. Her physical examination is normal for a woman at 38 weeks’ gestation. Laboratory evaluation shows:
Leukocyte count 11,500/mm3
Hematocrit 33%
Platelets 212,000/mm3
BUN 12 mg/dL
Serum creatinine 0.6 mg/dL
A nonstress test is reactive, and ultrasound demon-strates an amniotic fluid index of 13 with a fetus in the 50th percentile for growth. Repeat evaluation several hours later demonstrates a blood pressure of 142/90 mm Hg with no proteinuria. Three days later the patient goes into labor and has a normal vaginal deliv-ery. At 6 weeks postpartum, her blood pressure is 110/74 mm Hg. Which of the following is the most like-ly diagnosis of this patient’s elevated blood pressure? (A) Chronic hypertension
(B) Eclampsia
(C) Gestational hypertension (D) Malignant hypertension (E) Preeclampsia
2. A woman comes to her physician for her first prenatal visit. Upon review of her past medical history, the physician notes that the patient has never had varicella zoster. She is otherwise healthy and reports no recent illnesses. She had experienced some mild nausea in the mornings. By her last menstrual period, she is at 8 weeks’ estimated gestational age; pelvic examination confirms this. The physician counsels her that most women who do not remember having the chickenpox actually do have evidence of immunity and recom-mends immunologic testing to assess her status, which she agrees to have done. The results show that she does not show any evidence of prior infection or immunity to the varicella virus. She denies any recent known exposure to people with varicella infections. On the basis of this finding, which of the following is the most appropriate management at this time?
(A) She should have an ultrasound now
(B) She should receive the varicella vaccination now (C) She should receive varicella zoster immunoglobulin
now
(D) She should start taking acyclovir
(E) She should be advised to try to avoid exposure to people who have chickenpox
3. A 58-year-old woman comes to the physician for an annual examination. She states that she has been feeling well for the past year. Her past medical history is unre-markable. Her past surgical history is significant for a total abdominal hysterectomy that was performed 18 years ago for fibroids. She takes no medications and is allergic to penicillin. Physical examination, including breast and pelvic exams, is normal for a 58-year-old woman who is status post hysterectomy. Her record shows that she has had normal Pap tests all her life. She now wants to know how often she needs to have Pap testing performed. Which of the following represents the correct Pap test screening interval for this patient? (A) Every year
(B) Every 2 years (C) Every 3 years (D) Every 5 years
(E) Routine Pap testing is not necessary for this patient
4. A 32-year-old Caucasian woman comes to the labor and delivery ward at 2 A.M. She has noted decreased fetal
movement during the day and had hoped that it would improve. Fetal movement remained decreased and she was too worried to sleep, so she came to the hospital. She is at 32 weeks’ gestation by last menstrual period, con-firmed by a 19-week ultrasound. She is feeling otherwise well. She denies any vaginal bleeding, leaking of amniotic fluid, uterine contractions, or trauma. She has no other medical problems. She denies any history of tobacco, alcohol, or drug use. Vital signs are unremarkable. Her abdomen is soft, gravid, and nontender, with a fundal height of 31 cm. Which of the following is the most appropriate next step in evaluation?
(A) Administer betamethasone (B) Administer oxytocin
(C) Monitor the fetal heart rate for 20 minutes (D) Order an ultrasound
(E) Perform a cesarean section
5. A 24-year-old woman has a 4-day history of malodor-ous discharge. She denies vaginal itching or burning or pain with intercourse. She has no chronic medical con-ditions and does not take any medications besides oral contraceptive pills. She is sexually active with one male partner and uses condoms for additional protection. On pelvic examination, her vulva, vagina, and cervix appear normal except for a thin, grayish-white mal-odorous discharge. The vaginal pH is 5.3. Examination of the discharge will most likely reveal which of the fol-lowing findings?
(A) Branching hyphae and spores on KOH
(B) Giant multinucleated cells with intranuclear inclusions on Wright stain
(C) Granular-appearing epithelial cells that are coated with coccobacillary organisms on saline
(D) Motile, flagellated organisms on saline
(E) Squamous cells with perinuclear halos on Pap smear
6. A 20-year-old primigravid woman at term arrives at the birthing suite complaining of lower abdominal pain. She is contracting every 1 to 2 minutes, and the fetal heart rate is 142/min and reactive. The woman’s cervix is 4 cm dilated, 100% effaced, and at high station with double footling presentation. Laboratory studies show: leukocyte count 13,500/mm3, hemoglobin 11.3 g/dL, platelets 60,000/mm3, glucose 80 mg/dL, A+, rubella immune, VDRL positive. The physician informs the anesthesiologist that although a cesarean section will likely be indicated soon, it is not an emergent situation. Which of the following is the best obstetric anesthesia for this patient?
(A) Epidural block (B) General anesthesia (C) Paracervical block (D) Pudendal block (E) Spinal block
7. A 33-year-old primigravid patient at 30 weeks’ gestation comes to the physician for a routine prenatal visit on the day after Christmas. She states that the baby is moving well, and that she has had no loss of fluid, vaginal bleed-ing, or contractions. Her examination is normal for a patient at 30 weeks’ gestation. She has heard from a few of her friends that she should be “immunized” during pregnancy and she wants more information. Which of the following immunizations should this patient be offered at this point in her pregnancy?
(A) Influenza (B) Measles (C) Rubella (D) Varicella
(E) No immunizations should be offered during pregnancy
8. A 30-year-old woman comes to the emergency depart-ment because of vaginal bleeding for the last 4 hours. The bleeding has been fairly constant and she has bled through two regular tampons in the last 4 hours. She does not feel any pelvic or abdominal pain. She is 10 weeks pregnant and has been receiving routine prenatal care at another hospital. This is her first pregnancy, and as far as she knows, she is healthy and there are no com-plications. Her temperature is 36.7 C (98 F), blood pressure is 150/95 mm Hg, and pulse is 80/min. A bimanual examination demonstrates a closed and effaced cervix that is oozing blood. Her uterus is 16-week sized. In addition to drawing blood and sending for laboratory studies, including a beta-hCG, a pelvic ultrasound is performed. Which is the most likely ultra-sonographic finding?
(A) An extrauterine pregnancy
(B) Fluid/tissue collection in the cul-de-sac (C) A ruptured adnexal cyst
(D) A tuboovarian abscess (E) A vesicular pattern
9. A young woman comes to the student health center for an annual physical examination and family planning. She is a healthy, sexually active 22-year-old woman who has had one previous normal, satisfactory Papanicolaou (Pap) smear. In the past 3 years she has had four male sexual partners and uses birth control pills and con-doms. She has no history of sexually transmitted dis-eases or cervical dysplasia. Aside from tobacco use, she has no significant past medical history. Vital signs and physical examination, including a bimanual pelvic examination, are unremarkable. A Pap smear is per-formed and sent for cytologic evaluation. Two weeks later the report comes back indicating an adequate sample with the presence of squamous epithelial cell abnormalities, specifically low-grade intraepithelial lesions (LSIL). Which of the following is an appropriate management strategy for this patient?
(A) Discussion of cold-knife conization (B) Immediate loop electrosurgical excision (C) Incidental finding, no additional treatment (D) Referral for a colposcopy
(E) Repeat Pap smear in 1 to 2 years
10. An 18-year-old primigravid woman at 39 weeks’ gesta-tion is sent to labor and delivery for inducgesta-tion of labor secondary to preeclampsia. She had an uncomplicated prenatal course until yesterday, when she began to feel like she had the flu. On evaluation at a prenatal visit today, her blood pressure was 150/100 mm Hg, with 2+ proteinuria. Examination reveals her cervix to be 3 cm dilated and 75% effaced. After initial evaluation in labor and delivery, an induction of labor is begun with oxy-tocin, and intravenous magnesium sulfate is started. For which of the following reasons is the magnesium sulfate given to this patient?
(A) To control hypertension (B) To control proteinuria (C) To prevent hemorrhage (D) To prevent seizures (E) To protect the neonate
11. A 39-year-old woman, gravida 2, para 1, at 10 weeks’ gestation comes to the physician for a prenatal visit. She has some nausea and vomiting but otherwise feels well. Two years ago she had a normal spontaneous vaginal delivery of an 8-pound boy after a prenatal course complicated by well-controlled chronic hypertension. She has had chronic hypertension since the age of 35 years. She takes labetalol and has no known drug aller-gies. Her examination is normal for a woman at 10 weeks’ gestation. This patient’s chronic hypertension places her at highest risk for which of the following complications of pregnancy?
(A) Down syndrome
(B) Intrahepatic cholestasis of pregnancy (C) Intrauterine growth restriction (D) Placenta previa
(E) Shoulder dystocia
12. A 20-year-old woman comes to the emergency room because of left-sided abdominal pain that has been wors-ening over the past 2 days. She has no other complaints. She is found to have a temperature of 38.3 C (101.1 F), abdominal tenderness, cervical motion tenderness, and adnexal tenderness. She is given the diagnosis of pelvic inflammatory disease, admitted to the hospital, and started on intravenous gentamicin and clindamycin. The patient improves in the first day, and 48 hours after admission the patient is feeling well with normal vital signs and a normal exam. Which of the following is the most appropriate next step in management?
(A) Discharge home off all medications
(B) Discharge home on doxycycline (orally) for 12 more days
(C) Continued intravenous antibiotics for 5 more days (D) Continued intravenous antibiotics for 12 more
days (E) Laparoscopy
13. A 29-year-old obese woman comes to the physician complaining of irregular vaginal bleeding. She also com-plains that she and her husband have been unable to conceive, despite unprotected sexual intercourse for the past 14 months. She does not take any medication and has no other medical conditions. Her menstrual periods were normal until 2 years ago. Examination reveals hir-sutism and slightly enlarged ovaries, bilaterally. Dehydroepiandrosterone and 17-OH progesterone lev-els are not elevated. Additional studies are most likely to reveal which of the following findings?
(A) Decreased levels of testosterone
(B) Increased levels of sex hormone binding globulin (C) An LH to FSH ratio of 3:1
(D) A mid-cycle temperature elevation (E) Normal sonographic images of the ovaries
14. A 20-year-old Italian gravida 2, para 1 woman who is at 20 weeks’ gestation comes to the physician for her sec-ond prenatal visit. Her medical history is unremarkable except that she has been taking phenobarbital for many years for a seizure disorder. Her lifestyle is free of risk from teratogens and unsafe practices. The laboratory studies from her first prenatal visit show: hemoglobin 10.2 g/dL, leukocyte count 12,000/mm3, platelets 224,000/mm3, MCV 84 fl, and RDW 13. Which of the following is the most likely cause of these findings? (A) Folate deficiency anemia
(B) Iron deficiency anemia (C) Physiologic anemia (D) Sickle-cell trait (E) Thalassemia
15. A 23-year-old primigravid woman at 26 weeks’ gesta-tion comes to the physician for a prenatal visit. Her pregnancy has been uncomplicated thus far. She is screened for gestational diabetes using the 50-g, 1-hour glucose test. Her result is 150 mg/dL. A 100-g, 3-hour glucose test is then performed that demonstrates an ele-vated fasting glucose and eleele-vated 2-hour value, but normal 1- and 3-hour values. This patient would be characterized as having diabetes in pregnancy of which of the following classes?
(A) Class A1 (B) Class A2 (C) Class B (D) Class H
(E) This patient does not have diabetes
16. A 28-year-old woman comes to the physician for an annual examination. She states that she has been doing well over the past year. She has one sexual partner and uses condoms with him every time. She was diagnosed with secondary syphilis at the age of 23 years and she was treated appropriately. All followup evaluations have been performed and she has not required any further treatment. Which of the following is this patient’s sero-logic testing most likely to demonstrate?
(A) RPR negative, FTA-ABS positive (B) RPR positive, FTA-ABS negative (C) RPR positive, TP-PA positive (D) VDRL negative, FTA-ABS negative (E) VDRL positive, TP-PA negative
17. A 27-year-old white woman, gravida 1, para 0, at 24 weeks’ gestation comes to the physician for a prenatal visit. Her singleton pregnancy has been uncomplicated thus far. She states that she is feeling well. Her weight is 115 pounds and she is 5 feet tall. Her blood pressure is 142/94 mm Hg. She has 2+ proteinuria on a protein dipstick evaluation. She has a fetal heart rate in the 150s and her fundal height is 24 cm. Which of the following is a significant risk factor for the development of preeclampsia in this patient?
(A) Age (B) Nulliparity
18. A 14-year-old girl is referred to the physician for pri-mary amenorrhea. She has never had a menses but does note some cyclic abdominal pain that seems to occur each month. She has no other medical problems and has never had surgery. She takes a multivitamin every day and has no known drug allergies. A thorough eval-uation of the patient, including imaging studies, reveals that the patient has Mayer-Rokitansky-Kuster-Hauser syndrome. Which of the following is this patient likely to require, given her condition?
(A) Creation of a neovagina (B) Creation of breasts
(C) Hormone replacement therapy (D) Intrauterine device
(E) Medroxyprogesterone acetate injections
19. A 33-year-old primigravid woman at 33 weeks’ gestation comes to the labor and delivery ward because of a gush of fluid from her vagina. Her pregnancy is significant for twins. Her prenatal course was uncomplicated. Evaluation shows that the presenting twin has ruptured membranes and is in breech presentation. The nonpre-senting twin is cephalic with normal amniotic fluid vol-ume. The patient is contracting painfully every 2 minutes and is 6 cm dilated. Which of the following is the most appropriate management?
(A) Cesarean delivery
(B) Forceps-assisted vaginal delivery (C) Magnesium sulfate
(D) Terbutaline
(E) Vacuum-assisted vaginal delivery
20. A 27-year-old primigravid woman at 18 weeks’ gestation comes to the physician for a prenatal visit. She states that she is feeling well except for some fatigue. The pregnancy has been uncomplicated thus far. The patient has no med-ical problems. On examination, the patient’s abdomen seems large for 18 weeks and an ultrasound is performed that demonstrates twins, with a male and a female fetus. Which of the following is the type of twin pregnancy that this patient is most likely to have?
(A) Dichorionic/diamnionic (B) Dichorionic/monoamnionic
21. A 56-year-old woman comes to the physician for a fol-lowup visit regarding hot flashes. Three months ago she was started on hormone replacement therapy (HRT) with an estrogen-progestin combination to treat her hot flashes. She says that they have improved significantly. She has no medical problems and takes no other medi-cations. She has no significant family history of heart disease, Alzheimer disease, breast cancer, or ovarian can-cer. Physical examination is normal. Together with improvement in her hot flashes, which of the following is most likely to be an effect of HRT in this patient? (A) A decrease in high-density lipoprotein (HDL)
cholesterol
(B) A decrease in low-density lipoprotein (LDL) cholesterol
(C) Prevention of Alzheimer disease (D) Prevention of breast cancer (E) Prevention of heart disease
22. A 39-year-old woman, gravida 3, para 2, at 37 weeks’ gestation comes to the emergency department because of profuse vaginal bleeding. Her prenatal course had been uncomplicated until she awoke this morning with gushes of blood from her vagina. She has no significant past medical or surgical history. On examination, her blood pressure is 102/74 mm Hg and pulse is 120/min. She has diffuse abdominal tenderness and her uterus feels firm. There is blood on her perineum and clots coming from her vagina. Her cervix is 2 cm dilated and 25% effaced. The fetal heart rate is in the 100s with decreased variability and late decelerations. Which of the following is the most appropriate next step in man-agement?
(A) Emergent cesarean delivery (B) Oxytocin induction (C) Prostaglandin induction (D) Terbutaline administration (E) Vacuum-assisted vaginal delivery
23. A 23-year-old woman has bilateral breast enlargement and tenderness that fluctuate with her menstrual cycle. She is generally healthy and exercises on a regular basis, however it is “painful” to run around the time that she is due for her period. She takes no medications and does not smoke cigarettes. Her great-grandmother was diagnosed with breast cancer at age 74 but the patient’s mother and grandmother are alive and healthy. On physical examination, the patient’s breasts are lumpy and she indicates a sensitive area with a discrete 1.6-cm nodule that has been persistently painful. A mammo-gram shows a discrete nodule. A needle is inserted into the nodule and clear fluid is withdrawn. The cyst resolves clinically. Which of the following is the most appropriate next step in management?
(A) Biopsy
(B) Cytology of cyst fluid
(C) Mammography in 1 to 2 weeks (D) Repeat exam in 4 to 6 weeks (E) Ultrasonography
24. A 21-year-old primigravid woman at 28 weeks’ gesta-tion comes to the emergency department because of vaginal bleeding. She states that approximately a cup of blood came out of her vagina. Her pregnancy had been complicated by hyperemesis gravidarum, but this resolved in the second trimester. Examination demon-strates blood pressure of 112/72 mm Hg and pulse of 80/min. The remainder of the examination is normal for a patient at 28 weeks’ gestation. An ultrasound is performed that shows the placenta to be at the edge of the internal cervical os. Which of the following is the most appropriate management?
(A) Admission and observation (B) Emergent cesarean delivery (C) Immediate induction of labor (D) Induction of labor at 39 weeks
25. A previously healthy, 31-year-old woman has a vaginal itch and discharge. She also complains of pain with urination and intercourse. She takes oral doxycycline daily for acne. Her sexual partner is asymptomatic. Examination reveals erythema and edema of the vulva and a thick, white, clumpy discharge. The vaginal pH is 4.4. The remainder of the examination is unremarkable. Potassium hydroxide application to a sample of the dis-charge shows pseudohyphae and spores. Which of the following is the most appropriate pharmacotherapy? (A) Acyclovir
(B) Azithromycin (C) Ceftriaxone (D) Clotrimazole (E) Metronidazole
26. A 41-year-old woman comes to the physician because of abdominal pain. She states that her last menstrual period was 8 weeks ago. A urine pregnancy test is positive. A pelvic ultrasound is performed that shows a gestational sac with a yolk sac and no fetal pole. HCG is 1,600 mIU/mL. One week later a repeat ultrasound continues to show a gestational sac with no yolk sac or fetal pole. Repeat hCG is 1200 mIU/mL. The patient states that she would prefer not to have any operative intervention if possible. Which of the following is the most appropriate management of this patient?
(A) Dilation and curettage (B) Expectant management (C) Laparoscopy
(D) Laparotomy (E) Methotrexate
27. A 22-year-old woman comes to the clinic at the hospi-tal for her usual prenahospi-tal visit. Her records indicate that she is at 33 weeks’ estimated gestational age by last menstrual period, confirmed by a 20-week ultrasound. Her pregnancy has been uncomplicated. When ques-tioned about how she has felt since her last visit, she mentions that she has not felt the baby move as much for the past few days. She has felt otherwise well. She is a nonsmoker and denies alcohol or drug use. She denies any vaginal bleeding, abdominal pain, leaking of amni-otic fluid, or uterine contractions. She denies any histo-ry of abdominal trauma. Vital signs are unremarkable. Her abdomen is soft and nontender. A nonstress test is performed and there are two elevations in the baseline fetal heart rate that are 10 beats above the baseline for 10 seconds. The baseline is at 150 and long-term vari-ability is present. There are no decelerations in the fetal heart rate. Which of the following is the most appropri-ate management at this time?
(A) A cesarean delivery for fetal distress (B) Antibiotics for intrauterine infection (C) Betamethasone for preterm delivery (D) Oxytocin to induce delivery
(E) Ultrasound evaluation of amniotic fluid, fetal movement, breathing, and tone
28. A 17-year-old primigravid patient at 26 weeks’ gestation comes to the emergency department because of a gush of fluid from her vagina a few hours ago. Her pregnan-cy had been uncomplicated. On physical examination, she is afebrile with normal vital signs. Her abdomen is nontender and appropriate size for 26 weeks. Sterile speculum examination demonstrates clear fluid coming from the vagina, which is Nitrazine positive. Ultrasound demonstrates a fetus in breech presentation with severe oligohydramnios. Which of the following is the most appropriate management?
(A) Admission and expectant management (B) Amnioinfusion
(C) Cesarean delivery
(D) Oxytocin induction of labor (E) Prostaglandin induction of labor
29. A 24-year-old gravida 2, para 1 woman comes to the labor and delivery floor at 34 weeks’ gestation complaining of vaginal bleeding. Upon further questioning she says she has been spotting bright red blood off and on throughout the day but never a large amount of blood. She thinks that it began after sexual intercourse. A pelvic ultrasound reveals a posterior fundal placenta, amniotic fluid index of 13 cm, and the presence of fetal heart tone as well as several fetal movements. The fetal heart-rate baseline is 143/min and reactive. Her previous pregnancy was a completely normal vaginal delivery. There is no local ten-derness or pain over the uterus. Which of the following is the most likely diagnosis?
(A) Cervical polyp
(B) Incomplete uterine rupture (C) Mild placental abruption (D) Placenta previa
(E) Vasa previa
30. A 19-year-old primigravid woman at 30 weeks’ gestation is sent to the labor and delivery ward by her primary obstetrician because of high blood pressure. Her blood pressure in the office was 142/94 mm Hg and she had 1+ proteinuria on urine dipstick. She states that she feels well, with no nausea, vomiting, epigastric pain, headache, or visual disturbances. Her blood pressure on labor and delivery is 140/92 mm Hg and she continues to have 1+ protein on the urine dipstick. The remainder of her phys-ical examination is normal. Laboratory studies show:
Hematocrit: 36%
Leukocyte count: 12,000/mm3 Platelet count: 210,000/mm3 Urea nitrogen (BUN): 8 mg/dL
Creatinine: 0.6 mg/dL
ALT: 15 U/L
AST: 16 U/L
Her fetus has a reactive heart rate tracing and normal size and amniotic fluid on ultrasound. Which of the fol-lowing is the most appropriate management?
(A) Admission and administration of corticosteroids (B) Admission and administration of oral magnesium (C) Discharge with followup in 3 weeks
(D) Immediate cesarean delivery (E) Immediate induction of labor
31. A 27-year-old woman at 30 weeks’ gestation comes to the physician for a routine prenatal visit. She has had an uneventful pregnancy but has a history of one previous cesarean section for breech presentation. At this visit, she tells the physician that she wants to have natural birth. Her records indicate that both of her previous incisions were in transverse fashion in the lower uterine segment. She is otherwise healthy and has had no other surgeries. Which of the following is the best next step in management?
(A) Discourage vaginal delivery (B) Discuss risks of vaginal delivery (C) Encourage forceps delivery
(D) Recommend an emergency cesarean section when she goes into labor spontaneously
(E) Schedule cesarean section at 38 weeks
32. A 23-year-old primigravid woman at 21 weeks’ gesta-tion by first day of the last menstrual period comes to the emergency department complaining of vaginal bleeding and cramping. Her temperature is 37.7 C (99.9 F), blood pressure is 105/65 mm Hg, and pulse is 97/min. Examination shows slow, active bleeding from an open cervical os. Pelvic ultrasound reveals a fetus without any fetal heart activity. Which of the following is the most likely diagnosis?
(A) Fetal demise (B) Inevitable abortion (C) Incomplete abortion (D) Missed abortion (E) Septic abortion
33. A 34-year-old woman reports to the hospital with com-plaints of decreased fetal movement for 2 days. She says that she is “2 weeks” from her due date and has felt oth-erwise well. She has experienced no abdominal pain or cramping and denies any vaginal bleeding or leaking of fluid. This pregnancy has been uncomplicated, but she is a one-pack-per-day smoker. She has no other medical problems. Her vital signs are unremarkable and her abdomen is nontender. The initial fetal monitoring strip is nonreactive and there were no accelerations with acoustic stimulation. A biophysical profile is ordered. The score is 2/10, with points off for nonreactive NST, oligohydramnios, and no fetal breathing or movement. Tone is reported as normal. Which of the following is the most appropriate management at this time? (A) Administer antibiotics
(B) Administer betamethasone
(C) Order a second biophysical profile for the morning (D) Perform an amniocentesis
(E) Prepare the patient for delivery
34. A 22-year-old woman, gravida 2, para 1, at 12 weeks’ gestation comes to the physician because of palpita-tions. She states that she feels like her heart is racing and that she is always hot. She has no significant past med-ical history. Her blood pressure is 108/68 mm Hg, pulse is 112/min, and respirations are 12/min. She has mild thyromegaly, but otherwise her physical examination is normal. Laboratory evaluation studies show:
Thyroid-stimulating hormone: undetectable Thyroxine: 5 ng/dL
Which of the following is the most appropriate man-agement?
(A) Propylthiouracil (B) Subtotal thyroidectomy (C) Supplemental thyroid hormone
(D) Thyroid ablation (with radioactive iodine) (E) Total thyroidectomy
35. A physician is paged to the delivery room to find that an infant’s head is crowning. While preparing for the deliv-ery, the physician is informed by the nursing staff that this is the patient’s second child. She has had an uncom-plicated pregnancy and labor. She has no other medical problems. A glance at the fetal monitor reveals that the fetal heart rate is 154/min. The infant’s head delivers spontaneously and it restitutes from an occiput anteri-or position to a right occiput transverse position. (The baby is facing the inside of the mother’s left thigh.) The head seems to retract back into the perineum and gen-tle traction in addition to the mother’s pushing effort does not accomplish delivery of the infant’s shoulders. At this point the physician should instruct the nursing staff to do which of the following?
(A) Apply fundal pressure to assist in delivery
(B) Bring the physician a vacuum extractor to aid in delivery
(C) Flex the mother’s hips so her thighs are on her abdomen
(D) Prepare for a C-section as the physician performs the Zavanelli maneuver
(E) Tell the patient that breaking the baby’s clavicle will be necessary to make room for delivery
36. A 26-year-old primigravid woman at 39 weeks’ gestation comes to the labor and delivery ward because of contrac-tions. She had an uncomplicated prenatal course. On ini-tial physical examination, she is found to be 5 cm dilat-ed, 90% effacdilat-ed, and 0 station, and there is evidence that her membranes have ruptured. Over the next 3 hours she progresses to 9 cm dilated, 100% effaced, and +1 station. Two hours later she remains at 9/100/+1; oxytocin is started and an intrauterine pressure catheter (IUPC) is placed. Two hours later she remains at 9/100/+1 and the IUPC demonstrates 250 Montevideo units/10 min peri-od. The fetal heart rate tracing is normal. Which of the following is the most appropriate next step in manage-ment?
(A) Amnioinfusion (B) Cesarean delivery (C) Fetal scalp sampling
(D) Prostaglandin E2administration (E) Vacuum-assisted vaginal delivery
37. A 36-year-old primigravid woman at term comes to labor and delivery because of contractions. Her prena-tal course was complicated by hypertension but was otherwise uncomplicated. She is found to be 6 cm dilat-ed, 100% effacdilat-ed, and +1 station. Three hours later, at 3:00 PM, she delivers a 9-pound, 6-ounce girl. By 3:15 PM her placenta has still not delivered, despite gentle
cord traction and the administration of oxytocin. There is no evidence of active bleeding. Which of the follow-ing is the most appropriate next step in management? (A) Dilation and curettage
(B) Expectant management (C) Exploratory laparotomy (D) Hysterectomy
(E) Manual removal of the placenta
38. A 20-year-old woman, gravida 3, para 3, comes to the physician because of a vaginal discharge. Eleven days ago the patient delivered a 7-pound, 9-ounce girl. Her prena-tal and postpartum courses were unremarkable until yes-terday, when she noted that her vaginal discharge appeared yellowish-white. The discharge does not have an odor. She feels well and has no other complaints. Her temperature is 36.7 C (98 F), blood pressure 112/76 mm Hg, pulse 78/minute, and respirations 12/min. Abdominal and pelvic examinations are normal. Speculum examination does reveal a yellowish-whitish discharge that has leukocytes and epithelial cells on microscopy. Which of the following is the most appropri-ate next step in management?
(A) Culture of the vaginal discharge (B) Dilation and curettage
(C) Reassurance and precautions (D) 7-day course of antibiotics (E) 3-day course of antibiotics
39. A 44-year-old woman, gravida 1, para 1, continues to have elevated temperatures despite antibiotics 5 days after an emergency cesarean delivery for abruption. Her prenatal course was complicated by severe hyperemesis gravi-darum in the first trimester. At 38 weeks she developed vaginal bleeding and had an emergency cesarean delivery for abruption. Two days postoperatively she developed a temperature to 38.8 C (101.8 F) and was started on gen-tamicin and clindamycin. On postoperative day 4 she continued to have temperatures and ampicillin was added. Today a pelvic CT scan was performed that showed enlargement of the right ovarian vein with vessel wall enhancement and a low-density lumen. Which of the following is the most likely diagnosis?
(A) Appendicitis (B) Endometritis (C) Placenta accreta (D) Retained placenta
(E) Septic pelvic thrombophlebitis
40. A 54-year-old woman has a 4-week history of intermit-tent vaginal bleeding. Her last menstrual period was at age 51. She has no other symptoms and does not take any medication. Physical examination is unremarkable except for obesity. Pelvic examination reveals a small amount of blood in the vaginal vault that appears to be coming out the cervical os. There is no uterine or adnexal masses or tenderness. Which of the following is the most appropriate management at this time? (A) Chemotherapy
(B) Endometrial sampling (C) Estrogen replacement therapy (D) Reassurance
41. A 36-year-old primigravid woman at 8 weeks’ gesta-tion comes to the physician for an initial prenatal visit. She is very concerned about this pregnancy because several years ago she aborted a pregnancy in the sec-ond trimester because of an unknown chromosomal abnormality discovered on amniocentesis after a rou-tine 18-week ultrasound. An ultrasound report from the previous pregnancy showed:
Bilateral shortened femur Thickened nuchal fold
Major endocardial cushion defect
She does not know the details from the autopsy per-formed on the previous fetus, however she was told that the “colored part” of her baby’s eye had dots like the “spokes of a wheel” and that the palms of the hands did not have the normal pattern of creases. Which of the following triple screen patterns is consistent with the patient’s previous pregnancy?
(A) hCG decreased, AFP increased, estriol increased (B) hCG increased, AFP decreased, estriol increased (C) hCG increased, AFP decreased, estriol decreased (D) hCG decreased, AFP decreased, estriol increased (E) hCG decreased, AFP decreased, estriol decreased
42. A 28-year-old woman comes to the clinic for a routine healthcare visit. She feels well and is currently without any medical complaints. She and her husband are plan-ning to have their first child, however, and she wishes to do everything possible to make sure the pregnancy goes well. Her past medical history is unremarkable and she takes no prescription medications. She does, however, occasionally use a variety of over-the-counter medica-tions. A review of the medications she has used in the past few months include acetaminophen, a combina-tion of aspirin and indomethacin for migraines, topical clotrimazole for vulvovaginitis, calcium carbonate for dyspepsia, and a daily multivitamin containing folate. The patient would like to know if any of these medica-tions should be avoided. Appropriate advice for this patient is to avoid or minimize the use of which of the following?
(A) Acetaminophen
(B) Aspirin and indomethacin
43. A 29-year-old woman comes to the physician because of a 1-week history of mucopurulent vaginal discharge. She is sexually active with two different men. Her last menstrual period was 2 weeks ago and was normal. Physical examination is unremarkable. A Pap smear is normal; however, a chlamydia probe is positive. Cultures for gonorrhea are negative. Which of the fol-lowing is the most appropriate treatment?
(A) Administer a single intramuscular dose of benza-thine penicillin G
(B) Prescribe a single oral dose of azithromycin (C) Prescribe a 14-day course of oral doxycycline (D) Prescribe a 14-day course of oral ofloxacin (E) Prescribe a 7-day course of oral metronidazole
44. A 39-year-old woman comes to the clinic for a routine healthcare checkup. The couple hopes to have a child, as neither had any children in their previous marriages. The woman has had no past medical illness, and knows of no diseases that run in her family. She has four sib-lingsall are healthy and two have healthy children of their own. She is concerned, however, that her age will put her potential child at risk. In discussing this patient’s family plans, it is important to advise that her child is at a significantly increased risk for which of the following?
(A) Abnormality of the X chromosome (B) No specific genetic abnormalities (C) Presence of an additional X chromosome (D) Sudden infant death syndrome
(E) Trisomy of chromosome 21
45. A 23-year-old primigravid woman at 39 weeks’ gestation arrives at the hospital and delivers a viable 2700-g baby girl with APGAR scores of 7 and 8 at 1 and 5 minutes, respectively. The woman is homeless and received no prenatal care. Almost immediately, the pediatricians notice that the baby has skin scarring on her extremities, abnormalities in the lens of the eye, and abnormal motor movements of her extremities. Which of the fol-lowing perinatal infections is most consistent with these findings?
46. An 18-year-old primigravid woman comes to the physi-cian for an initial prenatal visit. She thinks that her last menstrual period was about 8 weeks ago. She has had some irregular bleeding over the past few days. She has no medical history and no drug allergies. On physical examination her fundal height is consistent with a 12-week pregnancy. Ultrasound is performed and reveals a vesicular pattern consistent with hydropic chorionic villi. A serum hCG is performed that shows a level of 310,000 mU/mL. Complete blood count and chemistry panels are also performed and are normal, as is a chest x-ray. Which of the following is the most appropriate next step in management?
(A) Dilation and curettage
(B) Dilation and curettage, then methotrexate (C) Dilation and curettage, then combination
chemo-therapy
(D) Dilation and curettage, then radiation therapy (E) Hysterectomy
47. A 10-year-old female comes to the physician for an annual examination. She has been in good health for the past year except for occasional asthma flares that she controls with an albuterol inhaler. She takes no other medications. She has no medical problems. Physical examination is normal for an 11-year-old female. The patient’s mother wants to know when her daughter needs to begin having annual Pap smears. Which of the following represents the time at which this patient should begin having cervical cytology screening with Pap smears?
(A) Age 12, or with menarche
(B) Age 18, or with the onset of sexual activity (C) Age 21, or 3 years after the onset of sexual activity (D) Age 30, or 10 years after the onset of sexual activity (E) Pap tests will not be necessary in this patient
48. A 20-year-old woman, para 1, comes to the physician for a 6-week postpartum visit. She had a prenatal course complicated by gonorrhea and had a normal spontaneous vaginal delivery of an 8-pound, 8-ounce female 6 weeks ago. She states that she is doing well after her episiotomy pain resolved. She is breast-feeding well and plans to do so for 6 months. She has never used birth control before but would like to start. Which of the following is the most appropriate form of contra-ception for this patient?
(A) Combined oral contraceptive pill (B) Contraceptive vaginal ring
(C) Medroxyprogesterone acetate injectable suspension (D) Monthly contraceptive injection
(E) Transdermal contraception
49. A 31-year-old primigravid woman at 20 weeks’ gesta-tion comes to the physician for a prenatal visit. This pregnancy has been complicated by maternal diabetes. The patient is considered a class F diabetic, as she has diabetic nephropathy. She has no other medical prob-lems. She takes insulin. Examination is normal for a woman at 20 weeks’ gestation. This patient’s medical condition makes her pregnancy most likely to be com-plicated by which of the following conditions?
(A) Caudal regression syndrome (B) Placenta previa
(C) Preeclampsia (D) Shoulder dystocia (E) Stillbirth
50. A 37-year-old comes to the clinic complaining of abnormal menstrual periods. She has had two uncom-plicated full-term pregnancies. Her last delivery was 6 months ago, after which she had a postpartum tubal lig-ation. Her last menstrual period was 4 days late, and she has had daily vaginal spotting for the last 10 days. She is not breast-feeding. Her abdomen is soft, and there is no tenderness. A 4-cm, midline, well-healed incision is just below the umbilicus. The vulva and vagina are normal. The cervix is pink, and there is a small amount of blood in the cervical os. The uterus is anteverted, anteflexed, at the upper limits of normal size, and nontender to motion. There is a fullness in the right adnexa. Culdocentesis reveals 5 mL of nonclotting blood. Which of the following is the most likely diagnosis? (A) Dysfunctional uterine bleeding
(B) Ectopic pregnancy
(C) Post-tubal ligation syndrome (D) Ruptured corpus luteum cyst (E) Ruptured follicle cyst
1. C 2. E 3. E 4. C 5. C 6. B 7. A 8. E 9. D 10. D 11. C 12. B 13. C 14. C 15. B 16. A 17. B 18. A 19. A 20. A 21. B 22. A 23. D 24. A 25. D 26. B 27. E 28. A 29. A 30. A 31. B 32. A 33. E 34. A 35. C 36. B 37. B 38. C 39. E 40. B 41. C 42. B 43. B 44. E 45. E 46. A 47. C 48. C 49. C 50. B
Assessment Exam
Answers and Explanations
1. The correct answer is C. Hypertension during pregnancy
is very common, occurring in 12 to 22% of all pregnan-cies. It is also a very important condition in that hyper-tension during pregnancy causes a significant amount of maternal and fetal morbidity and mortality. Over the years, there has been much confusion regarding terminol-ogy for hypertensive disease during pregnancy. In the year 2000, the report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy was published. The document rec-ommends that the term “gestational hypertension” should be used to describe women who develop elevated blood pressure without proteinuria after 20 weeks’ gesta-tion and whose blood pressure returns to normal post-partum. Hypertension is defined as a systolic blood pres-sure of greater than or equal to 140 mm Hg or a diastolic blood pressure greater than or equal to 90 mm Hg that occurs after 20 weeks’ gestation in a woman with previ-ously normal blood pressure. This patient meets these cri-teria, and the most appropriate diagnosis for her is gesta-tional hypertension.
Pregnant women with chronic hypertension (choice A) will have a history of hypertension, an elevated booking blood pressure, the development of hypertension before 20 weeks’ gestation, or the persistence of elevat-ed blood pressures postpartum. This patient has none of these, and therefore has gestational hypertension. Eclampsia (choice B) describes the occurrence of seizures in a patient with preeclampsia. This patient did not have preeclampsia and she did not have a seizure; therefore, she does not have eclampsia.
Malignant hypertension (choice D) is a term typically used to describe very elevated blood pressures (e.g., >220 mm Hg systolic or >120 mm Hg diastolic) with evidence of end organ damage. The organ systems that are typically affected are the central nervous system, the cardiovascular system, and the kidneys. This patient does not have very elevated blood pressure, and she has no evidence of end organ damage.
Preeclampsia (choice E) is a syndrome defined by hypertension and proteinuria. It may also be associated with many other signs and symptoms, including headache, visual changes, epigastric pain, nausea and vomiting, elevated transaminases, elevated creatinine, and low platelets, among other things. This patient did have hypertension but no proteinuria or other findings, and therefore she does not have preeclampsia.
2. The correct answer is E. In pregnant patients with no
demonstrated immunity to the varicella zoster virus, it is important to avoid exposure. The virus is spread through respiratory droplets or close contact. There is
an incubation period after exposure, averaging 14 days. Affected individuals are contagious from 48 hours before the onset of the rash until all of the vesicular lesions crust over. Fetal infection can occur only if maternal infection does, and the transmission rates are very low. However, severe congenital malformations, such as cardiac anomalies, limb anomalies, and micro-cephaly, can occur.
Ultrasound is used to look for cases of fetal infection. It is used in patients with maternal infection. This patient has no signs of infection or even exposure, and an ultra-sound (choice A) is not needed at this time.
Varicella vaccination can be used in patients without documented immunity. However, it is a live virus and should not be administered to pregnant patients
(choice B). Ideally, this patient should have received the
vaccine as part of preconception counseling.
Varicella zoster immunoglobulin is used in patients without documented immunity who have a recent exposure, to try to prevent infection or serious compli-cations of infection. There is no such history in this case, and administration of immunoglobulin (choice
C) is not indicated.
Oral acyclovir can be used in pregnant patients that develop varicella. If started within 2 hours of develop-ing the rash, it can decrease the severity of symptoms. It has not been shown to decrease the rate of fetal infec-tion (choice D).
3. The correct answer is E. There is much confusion
regarding whether or not women who have had a total hysterectomy (i.e., a hysterectomy in which both the uterus and cervix are removed) continue to require routine Pap testing (i.e., cervical cytology screening). The Pap test is a very effective tool for detecting prema-lignant cervical abnormalities that can then be treated in order to prevent the progression to invasive disease. However, the question often arises as to whether or not Pap testing is needed once the cervix has been removed. To answer this question, it is important to realize that Pap testing in women who have had the cervix removed is performed in order to detect primary vaginal cancer. Primary vaginal cancer is very rare and represents only a very small fraction of all gynecologic malignancies. Studies have shown that women who have had a hys-terectomy and have no history of Pap smear abnormal-ity are at an exceedingly low rate of developing vaginal cancer. Therefore, according to the American College of Obstetricians and Gynecologists, women who have had a total hysterectomy and have no prior history of high-grade cervical intraepithelial neoplasia may discontinue screening. This patient should be told that given her
history of a total hysterectomy and a lifetime of normal Pap tests, she does not need to continue to have Pap testing performed.
To counsel this patient that she should have a Pap test every year (choice A), every 2 years (choice B), every 3 years (choice C), or every 5 years (choice D) would be incorrect. As discussed earlier, this patient is not at risk for cervical cancer—her cervix has been removed. She is also at very low risk of a primary vaginal cancer developing because she has a lifetime history of normal Pap tests. This patient, therefore, does not require rou-tine Pap testing.
4. The correct answer is C. Decreased fetal movement is a
common complaint in pregnancy, but it’s usually a false-positive. It can be a sign of fetal acidemia and may precede fetal death. Monitoring the fetal heart rate for periodic changes from baseline is an accepted method of fetal surveillance in such situations. A reactive non-stress test (NST) is defined as two or more fetal heart rate accelerations in a 20-minute period. Accelerations are defined as elevations in the fetal heart rate that peak at least 15 beats per minute above the baseline and last at least 15 seconds. The NST is based on the premise that fetal movement will result in elevations of the fetal heart rate. It is used as an indicator of fetal well-being and good autonomic function.
Betamethasone is administered to patients at risk of preterm delivery to promote fetal lung maturity. If eval-uations of this patient are not reassuring, she may have a preterm delivery. However, administration of betamethasone at this time (choice A) is not warranted. Induction with oxytocin (choice B), even in preterm gestations, is sometimes warranted. An example of this would be severe preeclampsia. However, there is no cur-rent indication for expedited delivery in this case. Evaluation of fetal well-being should be undertaken before a decision to induce is made.
Abruption may be a cause of decreased fetal movement and fetal death. Abruption is usually a sudden, catas-trophic event, and a cessation of fetal movement is more likely to be seen than a decrease. Symptoms of abruption include painful uterine contractions, uterine tenderness even without contractions, and vaginal bleeding. Risk factors for abruption include trauma, drug use, and ele-vated maternal blood pressure. None of this is present in this case, and evaluation by ultrasound (choice D) for abruption would not be warranted.
5. The correct answer is C. This patient has signs and
symptoms most consistent with bacterial vaginosis. Patients typically complain of a fishy smelling, thin, grayish-white vaginal discharge with a pH greater than 5.0. Epithelial cells with clumps of coccobacillary bac-teria are seen on saline wet mount. Irritation of the vaginal epithelium is not usually seen.
Branching hyphae and spores (choice A) are associated with an infection with Candida albicans, which is charac-terized by intense pruritus and a thick, white (“cottage-cheese”) discharge with a pH less than 4.5. This patient’s discharge is not consistent with a Candida infection. Giant multinucleated cells with intranuclear inclusions
(choice B) are associated with an infection with herpes
simplex virus, which is characterized by vesicular lesions and ulcers, paraesthesia, and dysuria. The vaginal pH is typically normal (less than 4.5). The diagnosis is con-firmed with viral cultures and scrapings. Giant multin-ucleated cells with eosinophilic intranuclear inclusions are seen when stained with Wright stain. A saline wet mount smear preparation is not used to diagnose herpes infections. Also, this patient’s discharge is not consistent with a herpes infection.
Trichomonas vaginalis infection is diagnosed by finding
motile, flagellated organisms (choice D) on a saline wet mount smear preparation. Patients with T. vaginalis typ-ically experience vulvar itching and burning, a “frothy” malodorous discharge, dysuria, dyspareunia, and fre-quency and urgency of urination. Vaginal and cervical petechiae (“strawberry cervix”) may be present. The vaginal pH is generally greater than 5.0. This patient’s presentation is more consistent with bacterial vaginosis than with a Trichomonas infection.
Squamous cells with perinuclear halos, known as koilo-cytes (choice E), are associated with an infection with the human papilloma virus (HPV), which is characterized by soft, fleshy lesions on the genital region (condyloma acuminata). The vaginal pH is typically normal (less than 4.5). The diagnosis is established with a biopsy of the lesions. A Pap smear may show koilocytes, which are cyto-logic changes associated with HPV. A saline wet mount smear preparation is not used to diagnose HPV. This patient’s signs and symptoms are inconsistent with HPV.
6. The correct answer is B. Even though this is not an
emergent procedure, the best obstetric anesthesia for this patient is general anesthesia with intubation. Conduction anesthesia, or any anesthesia that requires
An epidural block (choice A) is not the best option in someone with thrombocytopenia.
Neither a paracervical block (choice C) nor a pudendal block (choice D) makes sense for this patient. A cesare-an section requires pain reception blockage in the abdominal wall and uterus, not in the cervical or per-ineal areas.
A spinal block (choice E) is not the best option in some-one with thrombocytopenia due to the possibility of a large hematoma.
7. The correct answer is A. Infection with the influenza
virus can cause significant morbidity and mortality for pregnant women. Influenza A is the most common type that causes epidemic infections and these epidemics tend to occur during the winter. In most healthy adults, the infection is mild; however, if pneumonia develops the results can be fatal. Because of this, starting in 1998, the Centers for Disease Control and Prevention (CDC) has recommended vaccination for all pregnant women after the first trimester. The American College of Obste-tricians and Gynecologists (ACOG) recommends that all women who are pregnant in the second and third trimester during the flu season (October through March) should be vaccinated. It also recommends that women at high risk for pulmonary complications be vaccinated as well, regardless of trimester. There is no evidence that the influenza vaccine results in teratogenicity.
Measles (choice B) and rubella (choice C) vaccines are not recommended for pregnant women. These vaccines are typically combined as the measles-mumps-rubella vaccine, which is a live attenuated virus vaccine. These live attenuated virus vaccines are contraindicated in pregnancy.
Varicella (choice D) is also a live attenuated virus vac-cine and is, therefore, contraindicated in pregnancy. However, it has been given during pregnancy and no adverse outcomes have been reported.
Stating that no immunizations should be offered dur-ing pregnancy (choice E) is incorrect. As explained ear-lier, the influenza virus is recommended to all pregnant women in the second and third trimester during the flu season (October through March).
8. The correct answer is E. This patient has the classic
presentation of a molar pregnancy: heavy and painless bleeding in the first half of pregnancy, a large-for-dates uterus, and preeclampsia before 20 weeks’ gestation. In fact, some physicians argue that preeclampsia before 20 weeks’ gestation is pathognomonic of hydatidiform mole. In addition, you would expect this patient to have an abnormally elevated (higher than expected)
beta-hCG for dates. These patients also can show a grape-like cluster (abnormal placental tissue) protrud-ing from the cervical os. Treatment involves dilation and curettage with appropriate followup: chest x-ray (to rule out metastatic disease) and serial beta-hCG measurements. Ultrasound in these patients shows a classic vesicular pattern that is referred to as having a “snowstorm” appearance for hypervascular, cystic, molar placental and chorionic villus tissue.
An extrauterine, or ectopic, pregnancy (choice A), if associated with rupture, is painful and life threatening. There is associated hypotension and tachycardia. Fluid and tissue in the cul-de-sac (choice B) is usually indicative of endometriosis, which presents as cyclic abdominal pain without evidence of bleeding. It sub-sides during pregnancy.
A ruptured adnexal cyst (choice C) would not be expected to cause hemorrhage. It is usually painless, but may be associated with crampy pain. One would not expect the uterus to be enlarged either.
A tuboovarian abscess (choice D) is a serious complica-tion of pelvic inflammatory disease (PID). It does not cause vaginal bleeding or an enlarged uterus. Patients generally have fever and severe abdominal pain, in addition to other signs of infection.
9. The correct answer is D. Seven to ten percent of patients
have an abnormal Pap smear and require further workup. Low-grade intraepithelial lesions are often insignificant and either resolve spontaneously or are associated with only mild abnormalities on further eval-uation. A significant subset has more advanced disease, however, such as advanced dysplasia or invasive cervical cancer. Colposcopy involves the direct visualization of the cervix, with the application of acetic acid allowing the visualization and biopsy of areas of atypical epithelial cells, thus allowing a more definitive evaluation of the underlying pathology. Some physicians believe that the Pap smear can be repeated within 6 months, and then if abnormal, the patient should be sent for colposcopy. Either way, the question asks for an appropriate manage-ment strategy, and therefore sending the patient for a colposcopy is the best answer choice given.
Cold-knife conization (choice A) and loop electrosurgi-cal excision (choice B) are procedures used to remove cervical dysplasia or malignancy while leaving as much of the cervix intact as possible. Neither is indicated until further workup with colposcopy indicates what abnor-mality, if any, is present.
Although occasionally LSIL is an insignificant finding that resolves on its own, it cannot be ignored (choice C). In one series, 15% of patients with LSIL on Pap smear
were found to have significant dysplasia or invasive can-cer, whereas another 15% were found to have moderate dysplasia. Not following up on an abnormal Pap smear can have disastrous consequences.
A repeat Pap smear in 1 to 2 years (choice E) is usually an appropriate strategy for Pap smear reports that indi-cate an inadequate sample was obtained and there is no clinical suspicion of disease. It is not an appropriate approach to cellular dysplasia, though some physicians may repeat a Pap smear within a few months. Given that up to 30% of patients in some series have been found to have significant disease, delaying treatment for a year could prove disastrous.
10. The correct answer is D. Preeclampsia is a syndrome
characterized by hypertension and proteinuria. Edema once was considered part of the diagnostic triad of the illness but is no longer considered part of the diagnos-tic criteria. Together with hypertension and protein-uria, preeclampsia can manifest in a myriad of other ways. For example, preeclampsia can lead to hepatic injury, causing epigastric pain, nausea and vomiting, and elevated transaminase levels. Preeclampsia also can lead to renal injury with oliguria and an elevated crea-tinine. One of the most feared complications of preeclampsia is its effects on the nervous system. Severe preeclampsia sometimes is characterized by headache and visual changes. Even worse, preeclampsia can lead to eclampsia, which is the occurrence of seizures in a patient with preeclampsia. These seizures can lead to significant morbidity and mortality for the mother and fetus. To prevent seizures in preeclamptic patients, magnesium sulfate is given. For years there had been much controversy over the choice of agent to use in pregnant women to prevent seizures. Now, however, the preponderance of evidence favors the use of magne-sium sulfate to prevent seizures in patients with preeclampsia and to prevent further seizures in patients with eclampsia.
Magnesium sulfate can cause a lowering of blood pres-sure in some patients, but it is not given to patients with preeclampsia to control hypertension (choice A). Hypertension in a preeclamptic patient does not need to be treated unless pressures remain persistently in the 160s/110s mm Hg range. In patients in whom those pressures do exist, intravenous hydralazine or labetalol can be used.
Proteinuria is one of the findings in patients with
Magnesium sulfate is not given to patients with preeclampsia to prevent hemorrhage (choice C). There is some evidence that magnesium sulfate actually can prolong bleeding times to some degree.
Magnesium sulfate is not given to patients with preeclampsia to protect the neonate (choice E). There has been some evidence to suggest that magnesium sul-fate given to the mother may protect premature neonates from neurologic injury. This fetus is not pre-mature, however, and the magnesium is used in this case to prevent a maternal seizure.
11. The correct answer is C. Chronic hypertension is one of
the most common medical conditions that complicate pregnancy. Estimates are that approximately 5% of preg-nant women have chronic hypertension. It can cause sig-nificant maternal and fetal morbidity and mortality. The adverse effects of chronic hypertension during pregnancy include intrauterine growth restriction (IUGR), prema-ture birth, fetal demise, placental abruption, and cesarean delivery. How much harm the chronic hypertension caus-es during the pregnancy depends on how many years the woman has had hypertension and how well controlled or poorly controlled the condition has been. Patients with severe, chronic hypertension are at significant risk for having a fetus with IUGR. These patients should be mon-itored carefully during the pregnancy and, in particular, have regular ultrasounds to monitor fetal growth. Down syndrome (choice A) is a chromosomal disorder that is not known to be caused by chronic hyperten-sion. Increasing maternal age, however, is a risk factor for chronic hypertension and Down syndrome. Intrahepatic cholestasis of pregnancy (choice B) is a disorder that occurs during pregnancy in which patients suffer from intrahepatic cholestasis with severe pruritus. These patients often can show evidence of liver dysfunction with abnormal liver function tests. This condition does not seem to be related to chronic hypertension.
Placenta previa (choice D) is defined as implantation of the placenta over or near the internal os. Major risk fac-tors for placenta previa are advancing maternal age, multiparity, prior cesarean delivery, and smoking. The major risk factors for shoulder dystocia (choice E) are fetal macrosomia, maternal obesity, maternal dia-betes, multiparity, and postdates. Patients with chronic hypertension do not seem to be at increased risk for shoulder dystocia.
disorders include endometritis, salpingitis, oophoritis, and tubo-ovarian abscess. N. gonorrhoeae and C.
tra-chomatis are the organisms that are most commonly
implicated in pelvic inflammatory disease, but, in actual-ity, the infection is typically polymicrobial and can involve organisms found in the normal vaginal flora. Patients with PID can be treated as inpatients or outpa-tients depending on their disease severity, other medical problems, and their reliability. This patient was admitted and rapidly improved. Current recommendations for the treatment of PID are that an admitted patient may be discharged on oral medication within 24 hours of clini-cal improvement. Doxycycline continues to be the main-stay for completion of antibiotic therapy in patients with PID, and it should be given to complete a 14-day course of treatment (i.e., 12 more days in this case.)
To discharge this patient home off all medications
(choice A) would not be correct. PID can have
devas-tating long-term consequences for patients, including infertility and chronic pelvic pain. It is essential that a complete course of therapy be given to patients. For PID, the complete course is completion of 14 days of therapy.
To give this patient continued intravenous antibiotics for 5 more days (choice C) would not be necessary. Current recommendations are for a transition to oral antibiotics after 24 hours of clinical improvement. To give this patient continued intravenous antibiotics for 12 more days (choice D) certainly would not be nec-essary. As explained above, once clinical improvement is sufficiently established, discharge home on oral antibiotics is recommended.
Laparoscopy (choice E) would not be necessary in a patient with a sufficiently certain clinical diagnosis who improves on antibiotics, as this patient did.
13. The correct answer is C. This patient most likely has
polycystic ovary syndrome, which typically presents with obesity, irregular menstrual bleeding, hirsutism, and infertility. Instead of showing the characteristic hor-mone fluctuation of the normal menstrual cycle, the gonadotropins and sex steroids are in a steady state, resulting in anovulation and infertility. Increased LH levels cause increased ovarian follicular theca cell pro-ductions of androgens. The increased levels of androstenedione and testosterone (choice A) suppress hepatic production of sex hormone binding globulin
(choice B). The combined effect of increased total
testosterone and decreased sex hormone binding globu-lin leads to mildly elevated levels of free testosterone. This results in hirsutism. The LH to FSH ratio is elevat-ed, often to 3:1 (normal is 1.5:1 in ovulatory women).
A mid-cycle temperature elevation (choice D) would not typically be seen in anovulatory states.
Ultrasonography of the ovaries of patients with polycys-tic ovary syndrome typically shows multiple subcapsular cysts (“string of pearls” appearance) (choice E).
14. The correct answer is C. This patient’s hemoglobin is
below the nonpregnant reference range. Her MCV is between 80 fl and 100 fl and thus normocytic. The red cell distribution width (RDW) is also <15. She has ane-mia caused by volume expansion during pregnancy. Even though she has a risk factor for folate deficiency anemia (choice A) (phenobarbital), her MCV is 84 fl (normocytic). Folate deficiency anemia is macrocytic (MCV >100 fl).
Iron deficiency anemia (choice B) is microcytic (MCV <80 fl) and the RDW is >15.
Even though this patient is of Mediterranean descent, she does not automatically have thalassemia (choice E) or sickle-cell trait (choice D). In order to diagnose these conditions, you should perform serum electrophoresis. However, this patient most likely has physiologic anemia.
15. The correct answer is B. The classification of diabetes
during pregnancy was created by Priscilla White and col-leagues in the mid twentieth century. This classification allowed one to estimate the likelihood of stillbirth for a given patient with diabetes during pregnancy. Patients who are class A1 have gestational diabetes with a fasting plasma glucose <105 mg/dL and 2-hour postprandial glucose levels <120 mg/dL. The correct treatment for these patients is diet. Patients who are class A2 have ges-tational diabetes with an elevated fasting plasma glucose or elevated 2-hour postprandial glucose, and the correct treatment for these patients is insulin. This patient should be classified as having class A2 diabetes, because she has an elevated fasting glucose and elevated 2-hour postprandial value. She should be treated with insulin for the remainder of the pregnancy.
As described, class A1 (choice A) diabetes is character-ized by normal fasting glucose values. This patient has an elevated fasting glucose value, which makes her a class A2 diabetic.
Class B (choice C) diabetics are those whose onset of diabetes was after the age of 20 years and whose dura-tion of diabetes is less than 10 years. Class B diabetics also have no evidence of vascular disease. The correct treatment for class B diabetics is insulin.
Class H (choice D) diabetics are those women who are pregnant and have diabetes with evidence of heart dis-ease. These patients also should be treated with insulin. To state that this patient does not have diabetes (choice
E) is incorrect. She failed her glucose tolerance test with
abnormal fasting and 2-hour postprandial glucose val-ues. She is, therefore, a gestational diabetic class A2, and requires insulin during the pregnancy.
16. The correct answer is A. There are two different types
of serologic tests for syphilis: nontreponemal tests and treponemal tests. There are two major nontreponemal tests that are used: the rapid plasma reagin (RPR) and the venereal disease research laboratory (VDRL) tests. These tests detect antibodies that are formed in patients who are infected with Treponema pallidum, but these tests are not specific for infection with that organism. Patients may have a positive RPR or VDRL secondary to other conditions. The nontreponemal test antibody titers usually correlate with disease activity. For exam-ple, with treatment, a patient’s RPR titer may decrease from 1:32 to 1:4. Generally speaking, a fourfold change in titer (e.g., 1:4 to 1:16) in a nontreponemal test (i.e., RPR or VDRL) is necessary to see a clinically significant difference. Nontreponemal tests usually become non-reactive over time in appropriately treated patients, such as the patient described. (In a minority of cases, a patient has a serofast reaction in which low titers of nontreponemal antibodies persist for the life of the patient.) There are two major treponemal tests that are used: fluorescent treponemal antibody absorbed (FTA-ABS) and T. pallidum particle agglutination (TP-PA). The vast majority of patients who have reactive tre-ponemal tests have reactive tests throughout their lives. These treponemal tests remain reactive regardless of whether or not the patient is treated adequately. Furthermore, as opposed to the nontreponemal test antibody titers, treponemal test antibody titers correlate poorly with disease activity and should not be used to assess treatment response. This patient who had syphilis several years ago and was treated adequately most likely would have serology that demonstrates her to be RPR negative (a nontreponemal test that goes to negative over time with adequate treatment) and FTA-ABS positive (a treponemal test that remains positive for the lifetime of the patient).
This patient is not likely to have serology showing her to be RPR positive, FTA-ABS negative (choice B). Some patients do remain RPR positive (a so-called “serofast
This patient is less likely to have serology showing her to be RPR positive, TP-PA positive (choice C) than she is to have serology showing her to be RPR negative and TP-PA (or FTA-ABS) positive. An RPR positive, TP-PA positive is the serofast reaction that is seen in a minority of patients.
As explained, this patient is unlikely to have serology showing her to be VDRL negative, FTA-ABS negative
(choice D) or VDRL positive, TP-PA negative (choice E). 17. The correct answer is B. Preeclampsia is a syndrome
that is characterized by hypertension and proteinuria. Hypertension is defined as a systolic blood pressure greater than or equal to 140 mm Hg or a diastolic blood pressure greater than or equal to 90 mm Hg taken 6 hours apart. Proteinuria is defined as greater than or equal to 300 mg of protein in a 24-hour period or greater than 1+ on multiple urine dipstick evaluations. Preeclampsia is a relatively common disease, with 5 to 8% of women developing the condition during preg-nancy, but the exact percentage depends very much on the population selected. Nulliparity is one of the most important risk factors for the development of preeclampsia. Estimates from large studies are that approximately 8% of nulliparous women develop preeclampsia and approximately 3% have severe disease. Age (choice A) is a risk factor for the development of preeclampsia, but the most important age category is women older than 35 years of age. Women who are older than 35 years have a significantly increased risk for developing preeclampsia compared with younger women. This patient is 27 years old and is, therefore, not at increased risk based on age.
Having a singleton gestation (choice C) does not place a woman at increased risk for the development of preeclampsia. Multiple gestation, however, is a highly significant risk factor for the development of preeclampsia. Estimates are that with a twin gestation the risk for developing preeclampsia is 10 to 15%. Obesity is a risk factor for the development of preeclampsia. This patient’s weight (115 pounds)
(choice D), however, does not put her in the obese
cat-egory. She would not, therefore, be at increased risk for the development of preeclampsia based on her weight. Race or ethnicity is considered an important risk factor for the development of preeclampsia, but it is African American ethnicity and not white race (choice E) that is considered to be the high-risk category.
