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Block 18 Explanations 1) A 31-year-old woman comes to the physician for follow-up after an abnormal Pap test and cer ical biopsy! "he patient#s Pap test showed a hi$h-$rade s%uamous intraepithelial lesion &'()*+)! "his was followed by colposcopy and biopsy of the cer ix! "he biopsy specimen also demonstrated '()*+! "he patient was counseled to under$o a loop electrosur$ical excision procedure &+EEP)! ,hich of the followin$ represents the potential lon$-term complications from this procedureA! Abscess and chronic pel ic inflammatory disease B! .er ical incompetence and cer ical stenosis .! .onstipation and fecal incontinence /! 'ernia and intraperitoneal adhesions E! 0rinary incontinence and urinary retention Explanation1 "he correct answer is B! "he loop electrosur$ical excision procedure &+EEP) is relati ely simple and can be performed in the outpatient settin$ with local anesthesia! "he procedure in ol es usin$ a wire loop to excise lesions of the transformation 2one! A benefit of +EEP3 alon$ with its ease of performance3 is that it pro ides tissue that can be examined histolo$ically! "he most appropriate candidates for +EEP are women with hi$h-$rade s%uamous intraepithelial lesions &'()*+)! "he immediate risks of +EEP are bleedin$ and infection! "he possible lon$-term risks include cer ical incompetence and cer ical stenosis! "hese may seem like exact opposites3 but +EEP can lead to both of them because3 to a certain extent3 it in4ures the cer ix! *f the body#s response to this in4ury is with 5too much5 scarrin$3 then cer ical stenosis can result! *f too much of the cer ix is in4ured3 the cer ix may be too weakened to carry a pre$nancy to term3 and cer ical incompetence may result! Abscess and chronic pel ic inflammatory disease &choice A) are not known to be lon$-term complications of the procedure! .onstipation and fecal incontinence &choice .) should not be caused by +EEP! +EEP in ol es the distal portion of the cer ix and should not in ol e the intestines or rectum at all! 'ernia and intraperitoneal adhesions &choice /) should not result from +EEP! "he procedure does not in ol e entry into the peritoneal ca ity6 therefore3 there should be no risk of hernia or intraperitoneal adhesions! 0rinary incontinence and urinary retention &choice E) are not known to be lon$-term complications from +EEP3 as the procedure does not in ol e the bladder! -------------------------------------------------------------------------------7) A 78-year-old woman3 $ra ida 73 para 73 comes to the physician to ha e her staples remo ed after an electi e repeat cesarean deli ery! 'er pre$nancy course was uncomplicated! )he states that she is doin$ well except that since the deli ery she has noticed some episodes of sadness and tearfulness! )he is eatin$ and sleepin$ normally and has no stran$e thou$hts or thou$hts of hurtin$ herself or others! Physical examination

is within normal limits for a patient who is status post cesarean deli ery! ,hich of the followin$ is the most likely dia$nosisA! 9aternity blues B! Postpartum depression .! Postpartum mania /! Postpartum psychosis E! Poststerili2ation depression Explanation1 "he correct answer is A! 9aternity blues is the term used to describe a common postpartum reaction that occurs in :; to 8;< of postpartum patients! *t is characteri2ed by tearfulness3 restlessness3 and anxiety! )ymptoms typically start in the first few days postpartum and resol e within 7 weeks! 'owe er3 certain patients continue to ha e the symptoms for se eral weeks! 9any symptoms may be seen in association with this disorder includin$ headache3 backache3 fati$ue3 for$etfulness3 insomnia3 weepin$3 depression3 anxiety3 and ne$ati e feelin$s toward the newborn infant! *nterestin$ly3 another component of the syndrome may be episodes of elation3 and such mood lability can be especially distressin$ for the new mother! *t is unclear what the etiolo$y of these symptoms is! .ertainly3 the postpartum period with a newborn can be stressful and life chan$in$3 which can certainly lead to mood chan$es and a number of emotional responses! )ome researchers ha e ar$ued that chan$es in hormone le els are at the root of the maternity blues3 but this has ne er been definiti ely pro en! "his patient does not ha e e idence of a true postpartum depression &e!$!3 insomnia3 lack of appetite3 or anhedonia) or postpartum psychosis &e!$!3 bi2arre thou$hts) and she does not ha e any thou$hts of hurtin$ herself or her baby! "herefore3 the most likely dia$nosis is maternity blues and she should be $i en support and reassurance! "he patient must also be cautioned3 howe er3 that if her symptoms do not resol e3 or if they worsen3 then she must call or return! Postpartum depression &choice B) is a depression that occurs in about 1;< of postpartum women and it is more serious than the maternity blues! )ymptoms may include sleep disturbances and chan$es in appetite! Postpartum mania &choice .) or postpartum psychosis &choice /) is a psychiatric disorder that occurs in about 1 per 13;;; deli eries! *t is characteri2ed by se ere anxiety3 a$itation3 disordered thou$hts3 and confusion! 'ospitali2ation is re%uired! Poststerili2ation depression &choice E) is a depression that is seen in women followin$ a tubal li$ation or other form of permanent sterili2ation! "his patient did not ha e a sterili2ation procedure! -------------------------------------------------------------------------------3) A 77-year-old primi$ra id woman comes to the labor and deli ery ward at term with re$ular3 painful contractions! 'er prenatal course was unremarkable! )he has a past medical history si$nificant for mitral al e prolapse with re$ur$itation demonstrated on echocardio$raphy! )he takes no medications and has no aller$ies to medications! Examination shows that her cer ix is = centimeters dilated and the fetus is in ertex presentation! "he fetal heart rate is reassurin$! ,hich of the followin$ is the most appropriate mana$ement of this patientA! Administer intra enous antibiotics throu$hout labor! B! Administer intra enous antibiotics 3; minutes prior to the deli ery!

.! Administer intra enous antibiotics after the cord is clamped! /! Administer intra enous antibiotics six hours after the deli ery! E! Antibiotic prophylaxis is not necessary Explanation1 "he correct answer is E! Bacterial endocarditis is a potentially life-threatenin$ infection that can de elop in patients with structural cardiac disease who are exposed to bacteremia! "he risk of de elopin$ endocarditis depends upon both the cardiac condition and the nature of the procedure! "he American 'eart Association periodically publishes $uidelines for the pre ention of bacterial endocarditis! Accordin$ to the American 'eart Association $uidelines3 antibiotic prophylaxis is not necessary for cesarean deli ery or normal a$inal deli ery! "he possible exception to this is for patients with 5hi$h risk5 cardiac conditions3 which include women with a history of endocarditis3 or who ha e prosthetic heart al es3 complex cyanotic con$enital heart disease3 or sur$ically corrected systemic pulmonary shunts! 9itral al e prolapse if associated with mitral re$ur$itation &demonstrated by /oppler or a murmur) is considered a moderate risk condition and therefore antibiotic prophylaxis is not necessary! "o administer intra enous antibiotics throu$hout labor &choice A)3 to administer intra enous antibiotics 3; minutes prior to the deli ery &choice B)3 to administer intra enous antibiotics after the cord is clamped &choice .)3 or to administer intra enous antibiotics six hours after the deli ery &choice /) would not be necessary! As explained abo e3 mitral al e prolapse with re$ur$itation is considered to be a moderate risk condition and3 for these conditions3 antibiotic prophylaxis to pre ent bacterial endocarditis is not necessary! -------------------------------------------------------------------------------=) A 7>-year-old primi$ra id woman at =7 weeks# $estation comes to the labor and deli ery ward for induction of labor! "he prenatal course was si$nificant for a positi e $roup B )treptococcus culture performed at 3: weeks! Antenatal testin$ o er the past 7 weeks has been unremarkable! "he patient is started on lactated ?in$er#s *@ solution! )terile a$inal examination shows that the patient#s cer ix is lon$3 thick3 and closed! Prosta$landin &P(E7) $el is placed into the a$ina3 and electronic fetal heart rate monitorin$ is continued! *n approximately >; minutes3 the fetal heart rate falls to the A;s3 as the tocodynamometer shows the uterus to be contractin$ e ery 1 minute with essentially no rest in between contractions! ,hich of the followin$ was most likely the cause of the uterine hyperstimulationA! *nfection B! *@ fluids .! Postdates pre$nancy /! Prosta$landin &P(E7) $el E! @a$inal examination Explanation1 "he correct answer is /! Prosta$landin &P(E7) $el is widely used for labor induction! *n simple terms3 it is used 5to soften5 an unfa orable cer ix3 to make the cer ix more fa orable for induction! *t has been shown to lead to an impro ement in the Bishop#s score3 a shorter duration of labor3 a

need for lower maximal doses of oxytocin3 and a reduced incidence of cesarean deli eries! P(E7 $el can also cause uterine contractions! Bne of the ma4or side effects with P(E7 $el is uterine hyperstimulation! "his occurs when uterine contractions come one ri$ht after the other3 or when there is a tetanic contraction &a prolon$ed uterine contraction with no rest period)! *n this settin$3 the fetus can become hypoxic with a resultant bradycardia! "his patient had the $el placed and >; minutes later had uterine hyperstimulation! *nfection &choice A) has not been shown to cause uterine hyperstimulation! "his patient#s $roup B )treptococcus coloni2ation is likely noncontributory! *@ fluids &choice B)3 unless oxytocin is present3 do not cause uterine hyperstimulation! Postdates pre$nancy &choice .) is the reason for this patient#s induction and not likely the direct cause of her uterine hyperstimulation! @a$inal examination &choice E) does not usually cause uterine hyperstimulation! @a$inal examination with a cer ical examination can be used for fetal scalp stimulation-rubbin$ the baby#s head to pro oke an acceleration of the fetal heart rate! 'owe er3 this does not usually pro oke uterine hyperstimulation! -------------------------------------------------------------------------------:) A 1>-year-old female comes to the physician because of an increased a$inal dischar$e! )he de eloped this symptom 7 days a$o! )he also complains of dysuria! )he is sexually acti e with one partner and uses condoms intermittently! Examination re eals some erythema of the cer ix but is otherwise unremarkable! A urine culture is sent which comes back ne$ati e! )exually transmitted disease testin$ is performed and the patient is found to ha e $onorrhea! ,hile treatin$ this patient#s $onorrhea infection3 treatment must also be $i en for which of the followin$A! Bacterial a$inosis B! .hlamydia .! 'erpes /! )yphilis E! "richomoniasis Explanation1 "he correct answer is B! "his patient has a $onorrhea infection! (onorrhea is one of the most pre alent sexually transmitted diseases &)"/s) in the 0nited )tates! *t is more common in patients of lower socioeconomic status3 patients with multiple sexual partners3 and in urban settin$s! "he causati e or$anism is C! $onorrhoeae3 a $ram-ne$ati e aerobic diplococcus! 0p to 8;< of women that are infected with the or$anism will ha e no symptoms at all or only a$ue symptoms! )ymptoms that are fre%uently noted are a$inal dischar$e3 postcoital spottin$3 and urinary symptoms if the urethra is in ol ed! Examination may re eal a cer icitis3 althou$h this is not always present! A patient found to ha e $onorrhea should be treated with intramuscular ceftriaxone or oral cefixime3 ofloxacin3 or ciprofloxacin! "hese medications will effecti ely eradicate the $onococcus! 'owe er3 because .hlamydia trachomatis can be isolated in up to :;< of women with $onorrhea and because women treated for $onorrhea only may soon $o on to de elop .hlamydia or pel ic inflammatory disease &P*/)3 any woman recei in$ treatment for $onorrhea should also be treated for .hlamydia! "reatment of .hlamydia is with a2ithromycin or doxycycline! *t is also

essential that this patient#s partner be treated as well! ,hen treatin$ a patient for $onorrhea3 there is no need to treat the patient with metronida2ole to treat bacterial a$inosis &choice A) as well3 unless there is e idence of a bacterial a$inosis ! 'erpes &choice .) often presents as painful esicles and ulcers! Patients with $onorrhea do not need to be treated for herpes as well3 unless there is e idence for herpes infection! Patients with $onorrhea are at increased risk of ha in$ other sexually transmitted diseases3 includin$ syphilis &choice /)! *t would be prudent to check this patient for syphilis with a blood test! 'owe er3 in the absence of a positi e syphilis test3 patients with $onorrhea do not need to be treated for syphilis! "richomoniasis &choice E) is treated with metronida2ole! A$ain3 as with bacterial a$inosis3 herpes3 and syphilis3 unless there is e idence of "richomonas infection3 the patient does not needed to be treated for trichomoniasis! ------------------------------------------------------------------------------->) A 1>-year-old nulli$ra id woman comes to the emer$ency department because of hea y a$inal bleedin$! )he states that she normally has hea y periods e ery month but missed a period last month and this period has been unusually hea y with the passa$e of lar$e clots! )he has no medical problems3 has no history of bleedin$ difficulties3 and takes no medications! 'er temperature is 38 . &A8!> D)3 blood pressure is 11;E8; mm '$3 pulse is A>Eminute and respirations are 17Eminute! Pel ic examination shows a moderate amount of blood in the a$ina3 a closed cer ix3 and a normal uterus and adnexae! 'ematocrit is 3;<! 0rine h.( is ne$ati e! ,hich of the followin$ is the most appropriate mana$ementA! Expectant mana$ement B! 'ysteroscopy .! Bral contracepti e pills /! +aparoscopy E! +aparotomy Explanation1 "he correct answer is .! "his patient has menorrha$ia3 likely due to an ano ulatory cycle! /urin$ the first few years after menarche3 it is common for women to ha e some ano ulatory cycles and irre$ular menses! /urin$ an ano ulatory cycle3 because no e$$ is released and no corpus luteum is formed3 there is no pro$esterone production! "his lack of pro$esterone means that the endometrium is stimulated by unopposed estro$en! "his leads to a buildup of the endometrial linin$ and often3 when the period does come3 menorrha$ia! "he treatment for this type of bleedin$ is with oral contracepti e pills! "he pills3 by pro idin$ estro$en and pro$esterone3 can help to stabili2e the endometrium and halt the bleedin$! Because this patient is bleedin$ hea ily and now has a si$nificant hematocrit drop &3;<)3 it is reasonable to pro ide hi$h doses of hormones! A common method of doin$ this is to ha e the patient take three pills per day for three days3 followed by 7 pills per day for three days3 followed by one pill per day until the pack is finished! *t is important in this case to note that pre$nancy was ruled out with a ne$ati e urine h.( test! *t is essential to rule out pre$nancy in a youn$ woman who presents with bleedin$ from the a$ina! Expectant mana$ement &choice A) would not be appropriate! "his patient is losin$ enou$h blood to

ha e dropped her hematocrit to 3;<! *f one does not inter ene3 there is the risk that the patient will continue to bleed and to drop her hematocrit e en further! Patients with dysfunctional uterine bleedin$ such as this can lose enou$h blood to re%uire a blood transfusion with the correspondin$ risks &e!$! infection and transfusion reaction!) 'ysteroscopy &choice B) would not be the most appropriate option! ,ith such se ere a$inal bleedin$3 hysteroscopy will likely not pro ide sufficient isuali2ation of the endometrium! Also3 hysteroscopy exposes the patient to the risks of sur$ery &e!$! perforation of the uterus3 dama$e to internal or$ans) for a problem that can be mana$ed effecti ely medically! +aparoscopy &choice /) and laparotomy &choice E) would not be appropriate! "his patient is ha in$ uterine bleedin$ that is most likely comin$ from inside the uterus &i!e! the endometrial linin$)! +aparoscopy and laparotomy will pro ide a iew of only the exterior of the uterus &the serosal surface) and thus will not be an effecti e approach to this problem! -------------------------------------------------------------------------------8) A 17-year-old female comes to the physician because of a a$inal dischar$e! "he dischar$e started about 7 months a$o and is whitish in color! "here is no odor! "he patient has no complaints of itchin$3 burnin$3 or pain! "he patient started breast de elopment at A years of a$e and her pubertal de elopment has proceeded normally to this point! )he has not had her first menses and she is not sexually acti e! )he has no medical problems! Examination is normal for a 17-year-old female! 9icroscopic examination of the dischar$e shows no e idence of pseudohyphae3 clue cells3 or trichomonads! ,hich of the followin$ is the most likely dia$nosisA! Bacterial a$inosis B! .andida ul o a$initis .! Physiolo$ic leukorrhea /! )yphilis E! "richomoniasis Explanation1 "he correct answer is .! Physiolo$ic leukorrhea can be seen durin$ 7 different periods of childhood! )ome female neonates de elop a physiolo$ic leukorrhea shortly after birth as maternal circulatin$ estro$ens stimulate the newborn#s endocer ical $lands and a$inal epithelium! "he dischar$e in these neonates is often $ray and $elatinous! Physiolo$ic leukorrhea can also be seen durin$ the months precedin$ menarche! /urin$ this time3 risin$ estro$en le els lead to a whitish dischar$e not associated with any symptoms of irritation! "his patient has a whitish dischar$e3 no other symptoms3 and she has had normal pubertal de elopment up to this point! "he dischar$e itself has no characteristics of infection! "herefore3 physiolo$ic leukorrhea is the most likely dia$nosis! Bacterial a$inosis &choice A) is not the most likely dia$nosis in this patient because the dischar$e is not malodorous and there are no clue cells seen on microscopic examination of the dischar$e! .andida ul o a$initis &choice B) is not the most likely dia$nosis because the dischar$e is not thick and white &or 5cotta$e-cheese5-like) and the patient has no irritati e symptomatolo$y! )yphilis &choice /) most often presents with a painless ulcer &called a chancre) or is found with serolo$ic testin$! A nonmalodorous3 whitish a$inal dischar$e

in a 17-year-old female who is not sexually acti e is almost certainly not e idence of syphilis! "richomoniasis &choice E) is also hi$hly unlikely in this patient and the lack of trichomonads on the microscopic examination effecti ely rules out this dia$nosis! -------------------------------------------------------------------------------8) A 3=-year-old woman comes the physician because of lower abdominal crampin$! "he crampin$ started 7 days a$o! Examination is unremarkable except for a pel ic examination that re eals a 1;-week si2ed uterus! 0rine h.( is positi e3 and pel ic ultrasound re eals a 1;-week intrauterine pre$nancy with a fetal heart rate of 1>;! "he patient states that she is not sure whether to keep the pre$nancy! ,hich of the followin$ is the most appropriate next step in mana$ementA! .ounsel the patient or refer to an appropriate counselor B! Cotify the patient#s parents .! Cotify the patient#s partner /! )chedule a termination of pre$nancy E! "ell the patient that she is likely to ha e a miscarria$e Explanation1 "he correct answer is A! "he decision of whether to ha e a termination of pre$nancy is a deeply personal one! "his patient has 4ust been notified that she is pre$nant with a 1;-week fetus! )he is unsure whether she wants to keep her pre$nancy or terminate it! *n this settin$3 the most appropriate next step is to counsel the patient re$ardin$ her options or refer the patient for counselin$! *n a balanced way3 the patient should be fully informed of all of her options includin$ raisin$ the child herself3 placin$ the child up for adoption3 and abortion! "o notify the patient#s parents &choice B) is not appropriate! )uch an act would iolate the patient#s confidentiality! A 3=-year-old woman is an adult and issues of parental notification do not apply! "o notify the patient#s partner &choice .) is not appropriate! "his notification would also iolate confidentiality! "o schedule a termination of pre$nancy &choice /) would not be appropriate! "his patient has 4ust informed the physician that she is unsure what she wants to do! "o 4ust $o ahead and schedule the termination without proper counselin$ of the patient would not be a balanced or proper approach for the patient! "o tell the patient that she is likely to ha e a miscarria$e &choice E) is inappropriate! "his patient may ha e a miscarria$e3 as mi$ht any patient with a firsttrimester pre$nancy! 'owe er3 once an intrauterine pre$nancy with fetal cardiac acti ity is identified3 the risk of miscarria$e is approximately 1;<! "herefore3 she is most likely not to ha e a miscarria$e! -------------------------------------------------------------------------------A) A 7A-year-old woman comes to the physician for follow-up of a ri$ht breast lump! "he patient first noticed the lump = months a$o! *t was aspirated at that time3 and cytolo$y was ne$ati e3 but the cyst recurred about 1 month later! "he cyst was re-aspirated 7 months a$o and3 a$ain3 the cytolo$y was ne$ati e! "he lump has recurred! Examination re eals a mass at 1; o#clock3 approximately = cm from the areola! 0ltrasound demonstrates a cystic lesion! ,hich of the followin$ is the most appropriate next step in

mana$ementA! 9ammo$raphy in 1 year B! 0ltrasound in 1 year .! "amoxifen therapy /! Bpen biopsy E! 9astectomy Explanation1 "he correct answer is /! Breast lumps are a common complaint in women! 9any of these masses are beni$n processes! Beni$n conditions of the breast include fibrocystic disease3 fibroadenomas3 $alactoceles3 abscesses3 and necrosis! *t is appropriate to aspirate a palpable macrocyst in the breast6 the fluid should be placed on a slide and sent for cytolo$ic e aluation! *f the cytolo$y is ne$ati e3 no further treatment is needed! )ome would ar$ue that if the cyst recurs3 it may be aspirated a$ain! 'owe er3 when a lesion recurs twice3 as has occurred in this patient3 open biopsy is warranted! "o wait to perform mammo$raphy in 1 year &choice A) or ultrasound in 1 year &choice B) would be incorrect mana$ement! Dirst3 if a mali$nancy is present3 waitin$ another year will allow pro$ression of the cancer! )econd3 the mammo$ram is not definiti e! *ma$in$ can contribute information to the workup of a breast mass3 but the definiti e dia$nosis rests on histolo$ic e aluation! "amoxifen therapy &choice .) is used to both pre ent and treat breast cancer! 'owe er3 this patient does not yet ha e a dia$nosis! )he has a cystic mass that has been aspirated twice and has recurred twice! )he therefore re%uires a biopsy to establish a dia$nosis prior to the institution of any treatment! 9astectomy &choice E) would not be indicated for this patient! A$ain3 this patient does not ha e a dia$nosis3 and to perform a mastectomy for a recurrent cyst would be inappropriate! -------------------------------------------------------------------------------1;) A 78-year-old primi$ra id woman at 3A weeks# $estation comes to the labor and deli ery ward with a $ush of fluid and re$ular contractions! Examination shows that she is $rossly ruptured3 contractin$ e ery 7 minutes3 and that her cer ix is dilated to = cm! "he fetal heart rate tracin$ is in the 1=;s and reacti e! )he is admitted to labor and deli ery3 and o er the followin$ = hours she pro$resses to A cm dilation! B er the past hour3 the fetal heart rate has increased from a baseline of 1=; to a baseline of 1>;! Durthermore3 moderate to se ere ariable decelerations are seen with each contraction! "he fetal heart rate does not respond to scalp stimulation! "he decision is made to proceed with cesarean deli ery! ,hich of the followin$ is the reason for the cesarean deli ery and the preoperati e dia$nosisA! Detal acidemia B! Detal distress .! Detal hypoxic encephalopathy /! +ow neonatal AP(A? scores E! Con-reassurin$ fetal heart rate tracin$ Explanation1 "he correct answer is E! +abor and deli ery represents a process of stress for the fetus! ,ith each uterine

contraction3 blood flow to the placenta decreases3 and the fetus is exposed to transient hypoxia! As the labor pro$resses and more and more contractions occur3 this hypoxia can e entually lead to a chan$e from aerobic to anaerobic metabolism! "his chan$e can lead to a buildup of acid in the fetus3 or fetal acidemia! 'owe er3 most fetuses tolerate the stress of labor and deli ery 4ust fine! "he fetus has a ariety of protecti e mechanisms3 includin$ a blood bufferin$ system and the di in$ reflex &a lowerin$ of the heart rate in times of hypoxic stress)3 to protect it from becomin$ dan$erously acidemic! Electronic fetal monitorin$ is used to determine whether the fetus is becomin$ dan$erously acidemic or 5stressed5 durin$ labor so that deli ery can occur prior to hypoxic dama$e to or$ans! 0nfortunately3 electronic fetal monitorin$ is not a ery specific tool for identifyin$ fetal acidemia! 9any fetuses with a non-reassurin$ fetal heart rate tracin$ do not ha e acidemia and are not in distress! 'owe er3 it can be ery difficult to distin$uish nonacidemic fetuses with non-reassurin$ fetal heart rate tracin$s from acidemic fetuses with non-reassurin$ fetal heart rate tracin$s! "hus3 the deli ery of many fetuses is expedited because of the concern for fetal acidemia when3 in fact3 the fetus is not acidemic at all! "hus3 it is most accurate to state3 as is in this case3 that the fetus was deli ered because of the non-reassurin$ fetal heart rate tracin$! Detal acidemia &choice A) is not the reason for deli ery! *n fact3 there is a stron$ likelihood that this fetus is not acidemic at all! Detal distress &choice B) is not the reason for deli ery! "here is a stron$ likelihood that this fetus is perfectly healthy and will ha e hi$h neonatal AP(A? scores and no distress at all! Detal hypoxic encephalopathy &choice .) is not the reason for deli ery! "he desire to pre ent hypoxicEacidemic dama$e to or$ans3 includin$ the brain3 is the reason for expeditin$ deli ery! 'owe er3 the non-reassurin$ fetal tracin$ does not indicate that hypoxic encephalopathy is necessarily occurrin$! +ow neonatal AP(A? scores &choice /) can be a marker of fetal acidemia! 'owe er3 many fetuses with non-reassurin$ fetal heart rate tracin$s do not ha e low neonatal AP(A? scores! -------------------------------------------------------------------------------11) A 7A-year-old woman3 $ra ida 73 para 13 at 38 weeks# $estation comes to the labor and deli ery ward with fre%uent painful contractions! 'er prenatal course was si$nificant for a urine culture that showed 1;;3;;; colony-formin$ unitsEmilliliter of (roup-B streptococci and asthma3 for which she uses an albuterol inhaler! Examination shows that she is contractin$ e ery 7 minutes and her cer ix is : centimeters dilated and 1;;< effaced! ,hich of the followin$ medications should this patient be treated with durin$ labor and deli eryA! Betamethasone B! Dolic acid .! 9a$nesium sulfate /! Bxytocin E! Penicillin Explanation1 "he correct answer is E! "he (roup B )treptococcus &(B)) is a bacterium that is a part of the normal bacterial coloni2ation of many women! /urin$ pre$nancy3 as many as 7;-=;< of women will be coloni2ed with (B)! 9ost babies born to coloni2ed mothers will not de elop infection

with (B)! 'owe er3 approximately 1 to = < of neonates will de elop infection! "he likelihood of infection is increased if the mother has preterm labor and deli ery &F 38 weeks)3 prolon$ed rupture of the membranes &G18 hours)3 or intrapartum temperature $reater than 38!; . &1;;!= D)! "wo primary methods are used to determine which women will recei e antibiotics durin$ labor! "he first method is based upon risk factors! "he fi e risk factors are1 1! 'istory of a (B)-affected neonate! 7! 0rine culture with (B)! 3! Preterm labor &F38 weeks)! =! 9embranes ruptured for $reater than ei$hteen hours in labor! :! "emperature $reater than 38!; . &1;;!= D) in labor! A woman with any one of these fi e risk factors should recei e antibiotics in labor! "he second method is based on screenin$3 with pre$nant women bein$ screened for (B) at 3: to 38 weeks with a culture of the a$ina3 perineum3 and anus! ,omen should be screened only if they do not ha e a history of a (B)-affected neonate or (B) bacteriuria! "his patient has (B) bacteriuria6 therefore3 she did not under$o screenin$! )he should be treated with penicillin durin$ labor and deli ery! Betamethasone &choice A) is a corticosteroid that is $i en to women to accelerate fetal maturity to help pre ent neonatal respiratory distress syndrome and other se%uelae of prematurity! "his patient is at 38 weeks# $estation and3 therefore3 does not re%uire betamethasone! Dolic acid &choice B) is a supplement that women should take preconceptionally and durin$ pre$nancy &not durin$ labor and deli ery) to help pre ent neural tube defects! 9a$nesium sulfate &choice .) is used in obstetrics to pre ent preterm labor and for sei2ure prophylaxis! "his patient does not ha e preterm labor and does not ha e preeclampsia! Bxytocin &choice /) is $i en to women to induce or to au$ment labor! "his patient3 howe er3 appears not to need oxytocin as she is contractin$ e ery : minutes and pro$ressin$ in labor! -------------------------------------------------------------------------------17) A 31-year-old primi$ra id woman comes to the physician for a prenatal isit! )he is known to be '*@ positi e! )he also has asthma3 for which she uses an inhaler! )he had a dia$nostic laparoscopy at a$e 7; for pel ic pain and has had no other sur$eries! )he has no known dru$ aller$ies! Extensi e counselin$ is $i en to the patient re$ardin$ ertical transmission of '*@ to the fetus! *t is recommended to her that she take antiretro iral therapy durin$ the pre$nancy to decrease the ertical transmission rate! *t is also recommended to her that she ha e a scheduled cesarean deli ery! After consideration of these options3 the patient chooses not to take the antiretro irals and opts for a a$inal deli ery! ,hich of the followin$ represents the approximate risk of ertical transmission &from the mother to the fetus) for this patientA! 7< B! 8< .! 7:< /! :;< E! 1;;< Explanation1 "he correct answer is .! )tudies ha e demonstrated that in the absence of maternal treatment with antiretro iral therapy or scheduled cesarean deli ery3 the rate of ertical transmission is approximately 7:<! "hus3 all pre$nant women should be offered '*@ testin$ to identify those patients

who are infected so that they may recei e antiretro iral therapy and be offered scheduled cesarean deli ery to decrease the rate of ertical transmission! 7< &choice A) represents the approximate rate of ertical transmission in women who recei e antiretro iral therapy durin$ the pre$nancy and a scheduled cesarean deli ery &i!e!3 a cesarean deli ery prior to the onset of labor or rupture of membranes!) 8< &choice B) represents the approximate rate of ertical transmission when women are treated with antiretro iral therapy durin$ pre$nancy and the neonate is treated postpartum! "his rate was identified in the landmark study from the Pediatric A*/) .linical "rials (roup ;8> study! "his study showed that antepartum3 intrapartum3 and postpartum 2ido udine &H/@) use would reduce the ertical transmission rate from 7:< to 8<! :;< &choice /) and 1;;< &choice E) are incorrect! -------------------------------------------------------------------------------13) A 77-year-old woman3 $ra ida =3 para 33 at 38 weeks# $estation comes to the labor and deli ery ward with a $ush of fluid! )terile speculum examination re eals a pool of fluid that is nitra2ine positi e and forms ferns when iewed under the microscope! "he fetal heart rate is in the 1:;s and reacti e! An ultrasound demonstrates that the fetus is in the breech position! A cesarean deli ery is performed! /urin$ the operation3 the physician3 who has recei ed no recent immuni2ations3 is stuck with a needle that had been used on the patient! ,hich of the followin$ is this physician at $reatest risk of contractin$A! '*@ B! 'epatitis B .! 'epatitis . /! )cabies E! )yphilis Explanation1 "he correct answer is B! )tudies ha e shown that sur$eons can readily ac%uire hepatitis B irus from patients! "he risk of ac%uirin$ hepatitis B is si$nificantly hi$her than the risk for '*@3 and somewhat hi$her than the risk for hepatitis .! "hus3 it is essential that health care workers be immuni2ed a$ainst the hepatitis B irus! "he immuni2ation schedule is for administration of the accine at 13 73 and > months! "he .enters for /isease .ontrol and Pre ention recommends that post accination testin$ for antibodies be performed to identify an ade%uate response to the immuni2ation! *ndi iduals who do not demonstrate the formation of antibodies after the immuni2ations are $i en should be tested for hepatitis B surface anti$en to ensure that they ha en#t already been infected! ,ith immuni2ation3 the risk of ac%uirin$ hepatitis B from a needle stick in4ury is si$nificantly lessened! '*@ &choice A) can be transmitted throu$h needle-stick in4ury! 'owe er3 the risk of this transmission is less than that of hepatitis B in indi iduals who ha e not been immuni2ed! 'epatitis . &choice .) appears to be more transmissible throu$h needle-stick in4ury than '*@3 but less transmissible than hepatitis B! 'owe er3 because there is no immuni2ation for hepatitis . a ailable yet3 and because the infection is so widespread in the population3 the risk of transmission is of $ra e concern! )cabies &choice /) is a skin parasite that is transmitted throu$h physical contact!

)yphilis &choice E) is a sexually transmitted disease that is most often transmitted throu$h sexual contact! "ransmission throu$h needle-stick in4ury is not a primary route! -------------------------------------------------------------------------------1=) A =3-year-old African American woman comes to the physician because of her concern re$ardin$ breast cancer! )he has no complaints at present! *n past years3 she had noted bilateral breast tenderness prior to her menses3 but this has since abated! )he has no medical problems! )he had two cesarean deli eries3 but no other sur$eries! )he takes a low-dose oral contracepti e pill and has no known dru$ aller$ies! )he does not smoke3 and her family history is ne$ati e! Physical examination is normal! All mammo$rams &yearly since a$e =;) ha e been ne$ati e to date! )he wants to know whether B?.A1 and B?.A7 screenin$ would be appropriate for her! ,hich of the followin$ is the correct responseA! B?.A1 and 7 screenin$ is not recommended B! B?.A1 and 7 screenin$ should be performed after a$e :; .! B?.A1 and 7 screenin$ should be performed if breast pain recurs /! B?.A1 screenin$ is recommended E! B?.A7 screenin$ is recommended Explanation1 "he correct answer is A! Bf the cases of breast cancer that are heritable3 approximately 8;< are due to mutations in B?.A1 and B?.A7! B?.A1 is associated with hi$h risk for breast and o arian cancer! B?.A7 is associated with a hi$h risk of female and male breast cancer! Bn the basis of our current understandin$3 howe er3 less than 1;< of all breast cancer cases can be considered to be heritable! "herefore3 the total number of breast cancer cases associated with B?.A1 and B?.A7 mutations is a small percenta$e of the total number of breast cancer cases! Durthermore3 there are numerous mutations that can occur in the B?.A1 and B?.A7 $enes and can be related to an increased cancer risk! )ome patients who ha e a mutation associated with cancer will not $o on to de elop cancer! Bther patients may ha e a stron$ family history of breast cancer but no identifiable mutation! At present3 therefore3 screenin$ of the $eneral population is not recommended! "his patient has no family history and is not in a hi$h-risk $roup! 'er prior breast tenderness was likely mastal$ia related to the premenstrual phase! "herefore3 B?.A1 and 7 screenin$ would not be recommended for this patient! "o state that B?.A1 and 7 screenin$ should be performed after a$e :; &choice B) is incorrect! As noted abo e3 $i en the limitations of the testin$ for B?.A1 and 7 mutations3 screenin$ of the $eneral population is not recommended! "o state that B?.A1 and 7 screenin$ should be performed if breast pain recurs &choice .) is incorrect! "his patient does not need screenin$3 not because her breast pain has resol ed3 but rather because B?.A1 and 7 screenin$ is not appropriate for the $eneral population at this time! As noted abo e3 her breast pain was likely cyclic mastal$ia secondary to hormonal chan$es prior to menses! "o state that either B?.A1 screenin$ &choice /) or B?.A7 screenin$ &choice E) is recommended is not correct! As explained abo e3 screenin$ for neither of these is recommended! --------------------------------------------------------------------------------

1:) A 37-year-old woman comes to the hospital for an electi e repeat cesarean deli ery! Dour years a$o she had a primary cesarean deli ery for a nonreassurin$ fetal heart rate tracin$! "wo years a$o she chose to ha e an electi e repeat cesarean deli ery rather than attempt a a$inal birth after cesarean &@BA.)! 'er prenatal course was uncomplicated except that she has mitral al e prolapse! An echocardio$raph demonstrated the mitral al e prolapse3 but no other structural cardiac disease! ,hich of the followin$ is the correct mana$ement of this patientA! Administer intra enous antibiotics 3; minutes prior to the procedure B! Administer intra enous antibiotics immediately after the procedure .! Administer intra enous antibiotics for 7= hours after the procedure /! Administer oral antibiotics > hours after the procedure E! Co antibiotics are needed Explanation1 "he correct answer is E! 9itral al e prolapse affects approximately :< of women of childbearin$ a$e! .onse%uently3 the issue of mitral al e prolapse and the need for antibiotics comes up %uite often in obstetrics3 particularly with deli ery &either a$inal deli ery or cesarean deli ery)! Bacterial endocarditis is a life-threatenin$ infection that can de elop in patients with structural cardiac disease who are exposed to bacteremia! "he risk for any $i en procedure depends upon the nature of the procedure itself and on the nature of the cardiac lesion! Periodically3 the American 'eart Association publishes $uidelines for the pre ention of bacterial endocarditis! Accordin$ to the American 'eart Association $uidelines3 antibiotic prophylaxis is not necessary for cesarean deli ery or normal a$inal deli ery! "he possible exception to this is for patients with 5hi$h risk5 cardiac conditions3 which includes women with a history of endocarditis or who ha e prosthetic heart al es3 complex cyanotic con$enital heart disease3 or sur$ically corrected systemic pulmonary shunts! 9itral al e prolapse3 if associated with mitral re$ur$itation &demonstrated by /oppler or a murmur)3 is considered a moderate risk condition and3 therefore3 antibiotic prophylaxis is not necessary! "his patient3 therefore3 does not re%uire antibiotics prior to3 durin$3 or after her cesarean deli ery! "o administer intra enous antibiotics 3; minutes prior to the procedure &choice A)3 immediately after the procedure &choice B)3 7= hours after the procedure &choice .)3 or to administer oral antibiotics > hours after the procedure &choice /) would all be unnecessary! As explained abo e3 the reason for administerin$ antibiotics to women with structural cardiac disease is to pre ent bacterial endocarditis! Bacterial endocarditis is a potentially fatal condition! 'owe er3 there are different de$rees of structural cardiac disease! 9itral al e prolapse with re$ur$itation is considered to be a moderate risk condition! "he American 'eart Association does not recommend endocarditis prophylaxis for women with moderate risk conditions under$oin$ a$inal or cesarean deli ery! -------------------------------------------------------------------------------1>) A 38-year-old woman3 $ra ida =3 para =3 comes to the physician 8 days after a cesarean deli ery complainin$ of redness and pain at the leftmost aspect of her incision! 'er cesarean deli ery was performed secondary to a non-reassurin$ fetal heart rate tracin$! )he was feelin$ well after the operation until = days a$o3 when she de eloped

pain and redness around her incision! 'er temperature is 38 . &A8!> D)3 blood pressure is 118E88 mm '$3 pulse is 88Emin3 and respirations are 17Emin! "here is marked erythema and induration around the incision! At the left mar$in of the incision there is a fluctuant mass! ,hich of the followin$ is most appropriate next step in mana$ementA! Expectant mana$ement B! Bral antibiotics only .! *@ antibiotics only /! *ncision and draina$e E! +aparotomy Explanation1 "he correct answer is /! "his patient most likely has a wound abscess! ,hen antibiotic prophylaxis is used3 wound infections occur at a rate of approximately 1< after cesarean deli eries! 'owe er3 this patient appears to ha e more than a cellulitis! "he fluctuant mass at the leftmost aspect of the incision is hi$hly likely to be an abscess! "he proper treatment for a wound abscess is with incision and draina$e! "his patient is unlikely to impro e with expectant mana$ement &choice A)! An abscess almost always re%uires incision and draina$e for cure! Expectant mana$ement may lead to worsenin$ of the infection3 with the possibility of spread to ad4acent structures &e!$!3 fascia) or to bacteremia and sepsis! Bral antibiotics only &choice B) or *@ antibiotics only &choice .) may not resol e the abscess! Antibiotics often do not penetrate the abscess ca ity! +aparotomy &choice E) is probably not necessary for this patient! )he has a wound abscess that should be addressed with incision and draina$e! *n the process of the incision and draina$e3 the fascia should be checked to ensure that it is intact! As lon$ as the fascia is intact and there is no intra-abdominal process3 there is no need for laparotomy! -------------------------------------------------------------------------------18) A 3A-year-old woman3 $ra ida 33 para 73 at term comes to the labor and deli ery ward complainin$ of a $ush of fluid! Examination shows her to be $rossly ruptured3 and ultrasound re eals that the fetus is in ertex presentation! "he fetal heart rate is in the 17;s and reacti e! After a few hours3 with no contractions present3 oxytocin is started! "hree hours later3 the tocodynamometer shows the patient to be ha in$ contractions e ery minute and lastin$ for approximately 1 minute with almost no rest in between contractions! "he fetal heart rate chan$es from 17;s and reacti e to a bradycardia to the 8;s! )terile a$inal examination shows that the cer ix is > cm dilated! ,hich of the followin$ is the most appropriate next step in mana$ementA! /iscontinue oxytocin B! )tart ma$nesium sulfate .! Perform forceps assisted a$inal deli ery /! Perform acuum assisted a$inal deli ery E! Perform cesarean deli ery Explanation1 "he correct answer is A! "his patient has the findin$s most consistent with uterine hyperstimulation-more than : contractions in 1; minutes3 contractions lastin$ 7 minutes or more3 or contractions of

normal duration occurrin$ within 1 minute of each other and a non-reassurin$ fetal heart rate tracin$! Bxytocin is one of the most fre%uently used medications in the 0!)! *t is ery effecti e at producin$ contractions and used ery often for induction of labor! "he most common ad erse effect with oxytocin is a non-reassurin$ fetal heart rate pattern brou$ht about by uterine hyperstimulation! Because it has a ery short half-life &3-: minutes)3 discontinuin$ the oxytocin often resol es the hyperstimulation %uickly! *n this patient3 with a bradycardia to the 8;s3 this step is most appropriate! *n situations where the fetal heart rate tracin$ is not as non-reassurin$3 the oxytocin dosa$e may be reduced rather than discontinued completely! *f uterine hyperstimulation induced by oxytocin does not respond to shuttin$ the oxytocin off3 one can start ma$nesium sulfate &choice B) or $i e terbutaline! Both of these may be $i en intra enously to treat uterine hyperstimulation that does not respond to other measures! "o perform forceps-assisted &choice .) or acuum-assisted &choice /) a$inal deli ery would be contraindicated! "his patient#s cer ix is only > cm dilated! Dorceps and acuum are not used unless the cer ix is fully dilated! "o perform a cesarean deli ery &choice E) would not be appropriate prior to tryin$ other steps! "his fetus most likely is not sufferin$ a metabolic acidemia3 based on the fact that its reassurin$ heart rate tracin$ is in the 17;s and reacti e! *ts bradycardia is directly related to the hyperstimulation3 which is caused by the oxytocin! "hus3 efforts should be made to mana$e the fetal distress with conser ati e measures prior to resortin$ to cesarean deli ery! -------------------------------------------------------------------------------18) A 78-year-old primi$ra id woman at term comes to the labor and deli ery ward with a $ush of fluid and re$ular contractions! 'er prenatal course was remarkable for her bein$ ?h ne$ati e and antibody ne$ati e! 'er husband is ?h positi e! B er the followin$ 1; hours3 she pro$resses in labor and deli ers a 3>;;-$ boy ia a normal spontaneous a$inal deli ery! "he placenta does not deli er spontaneously3 and a manual remo al is re%uired! "o determine the correct amount of ?ho(A9 &anti-/ immune $lobulin) that should be $i en3 which of the followin$ is the most appropriate laboratory test to sendA! .omplete blood count B! Ileihauer-Betke .! +i er function tests /! Prothrombin time E! )erum potassium Explanation1 "he correct answer is B! ,omen who are ?h ne$ati e are at risk for de elopin$ ?h isoimmuni2ation! ?h isoimmuni2ation occurs when an ?h-ne$ati e mother becomes exposed to the ?h anti$en on the red blood cells of an ?h-positi e fetus! "his exposure may lead the mother#s immune system to become sensiti2ed to the ?h anti$en such that in a future pre$nancy with an ?h-positi e fetus3 the mother#s immune system may 5attack5 the ?h anti$en on the fetal red blood cells! "his immune response may lead to the de elopment of fetal anemia3 hydrops3 and death! "o pre ent ?h isoimmuni2ation from occurrin$3 ?h-ne$ati e women who are not ?h alloimmuni2ed should recei e ?ho(A9 &anti-/ immune $lobulin) at 78 weeks# $estation3 within 87 hours after the birth of an ?h-positi e infant3

after a spontaneous abortion3 or after in asi e procedures such as amniocentesis! ?ho(A9 should also be stron$ly considered in cases of threatened abortion3 antenatal bleedin$3 external cephalic ersion3 or abdominal trauma! "he amount that is usually $i en after the deli ery of an ?h-positi e fetus is 3;; J$! "his amount is sufficient to co er a fetal to maternal hemorrha$e of 3; m+ &or 1: m+ of fetal cells)! 'owe er3 some women will ha e a fetal to maternal hemorrha$e that is in excess of this 3; m+-especially in cases such as manual remo al of the placenta &like this patient had) or placental abruption! "o determine the amount of fetal to maternal hemorrha$e that occurred3 it is necessary to perform a Ileihauer-Betke test! "his acid-dilution procedure allows fetal red blood cells to be identified and counted! Inowin$ the amount of fetal to maternal hemorrha$e that took place allows the correct amount of ?ho(A9 to be $i en! A complete blood count &choice A) will demonstrate the amount of maternal hemorrha$e3 but not the amount of fetal to maternal hemorrha$e! +i er function tests &choice .)3 prothrombin time &choice /)3 and serum potassium &choice E) do not allow for the determination of the amount of fetal to maternal hemorrha$e! -------------------------------------------------------------------------------1A) A 77-year-old primi$ra id woman at term comes to the labor and deli ery ward because of painful contractions e ery 7 minutes! )he has had no $ush of fluid and no bleedin$ from the a$ina! 'er prenatal course was unremarkable! )he takes no medications and has no aller$ies to medications! Examination shows that her cer ix is > cm dilated and 1;;< effaced6 the fetus is at ; station! "he fetal heart rate has a baseline in the 1:;s and is reacti e! "he patient desires an epidural for pain relief! ,hich of the followin$ should be $i en orally shortly before the epidural is placedA! Antacid B! Antibiotic .! Aspirin /! .lear li%uid meal E! ?e$ular 5house5 meal Explanation1 "he correct answer is A! Aspiration pneumonitis is a ma4or cause of anesthesia-related death in obstetrics! 9ost often3 these aspiration e ents occur with the use of $eneral anesthesia! Pre$nant patients are at $reater risk for aspiration because of the delayed $astric emptyin$ that occurs durin$ pre$nancy and labor! Pre$nancy is associated with increased le els of pro$esterone and displacement of the pylorus by the pre$nant uterus! +abor is associated with pain and stress! All of these factors lead to delayed $astric emptyin$! Aspiration pneumonitis is caused by acidic $astric 4uices enterin$ the lun$s and inducin$ a sometimes-lethal chemical pneumonitis! ,hen epidural anesthesia is administered3 there is a risk of complications3 includin$ the de elopment of total spinal anesthesia! "he treatment for this complication is positi e-pressure entilation with 1;;< oxy$en administered throu$h an endotracheal tube! "herefore3 when an epidural is $oin$ to be placed3 the patient should be $i en an antacid &often 3; m+ of ;!3 m+E+ sodium citrate with citric acid3 called Bicitra) to increase the stomach p'! "his will help to pre ent aspiration pneumonitis should an aspiration e ent take place durin$ the administration of

$eneral anesthesia! *t is not necessary to $i e an antibiotic &choice B) prior to the administration of an epidural! Antibiotics are used durin$ labor for the pre ention of $roup B )treptococcus sepsis3 for patients with chorioamnionitis3 for patients in need of al e or endocarditis prophylaxis3 or durin$ cesarean deli ery for the pre ention of infection! Aspirin &choice .) is not $i en prior to the placement of an epidural! A clear li%uid meal &choice /) or a re$ular 5house5 meal &choice E) should not be $i en to patients prior to the placement of an epidural! *ntake of food or li%uids durin$ labor places the patient at $reater risk of aspiration pneumonitis! Patients in labor should be allowed small sips of water or ice chips! -------------------------------------------------------------------------------7;) A 3A-year-old woman3 $ra ida =3 para 33 comes to the physician for a prenatal isit! 'er last menstrual period was 8 weeks a$o! )he has had no abdominal pain or a$inal bleedin$! )he has no medical problems! Examination is unremarkable except for an 8week si2ed3 nontender uterus! Prenatal labs are sent! "he rapid plasma rea$in &?P?) test comes back as positi e and a confirmatory microhema$$lutination assay for antibodies to "reponema pallidum &9'A-"P) test also comes back as positi e! ,hich of the followin$ is the most appropriate pharmacotherapyA! Erythromycin B! +e ofloxacin .! 9etronida2ole /! Penicillin E! "etracycline Explanation1 "he correct answer is /! "his patient has syphilis! )yphilis is a disease caused by "reponema pallidum3 a spirochete! A painless ulcer3 called a chancre3 typically found on the a$ina or cer ix3 characteri2es primary syphilis! *f primary syphilis is untreated it can pro$ress to secondary syphilis3 which is characteri2ed by 5moth-eaten5 alopecia3 a maculopapular skin rash in ol in$ the palms and soles3 and white patches on the ton$ue! (umma formation3 cardiac lesions3 and central ner ous system abnormalities characteri2e tertiary syphilis! )yphilis in pre$nancy is associated with increased rates of preterm deli ery3 intrauterine $rowth retardation3 and fetal demise! 'owe er3 the most de astatin$ complication of syphilis in pre$nancy is con$enital infection! .on$enital infection of the fetus can lead to se ere fetal morbidity and mortality! "he key to pre entin$ con$enital infection of the fetus is ade%uate treatment of the mother! "herefore3 e ery woman should be tested for syphilis durin$ routine prenatal care! "he ?P? test and @enereal /isease ?esearch +aboratory &@/?+) are screenin$ tests for syphilis and are not entirely specific for "reponema pallidum infection! .ertain other conditions3 such as autoimmune syndromes and pre$nancy itself3 can $i e a falsely positi e ?P? test! "herefore3 the ?P? test should be followed up with a test that is specific for syphilis3 such as the 9'A-"P test! ,hen both of these tests are positi e and there is no history of syphilis infection and treatment3 then the patient should be treated with intramuscular penicillin! Erythromycin &choice A) is recommended by some as the first-line treatment for chlamydia in pre$nancy &others recommend a2ithromycin)! Erythromycin is not the dru$ of choice for

syphilis in pre$nancy! +e ofloxacin &choice B) and the other fluoro%uinolones are considered contraindicated in pre$nancy because of an association with musculoskeletal con$enital anomalies! 9etronida2ole &choice .) is used durin$ pre$nancy for the treatment of bacterial a$inosis and trichomoniasis! *t is not used for treatment of syphilis! "etracycline &choice E) is contraindicated durin$ pre$nancy because of effects on fetal bones and teeth! -------------------------------------------------------------------------------71) A >8-year-old woman comes to the physician because of pain with urination and fre%uent urination! )he has hypertension for which she takes a beta-blocker3 but no other medical problems! )he states that she is not sexually acti e! )he does not smoke and drinks cranberry 4uice daily! Examination shows mild suprapubic tenderness and $enital atrophy but is otherwise unremarkable! 0rinalysis shows :; to 1;; leukocytesEhi$h powered field &hpf) and : to 1; erythrocytesEhpf! ,hich of the followin$ is the most likely cause of the infectionA! .ardiac disease B! .ranberry 4uice in$estion .! 'ypoestro$enism /! Cephrolithiasis E! )exual intercourse Explanation1 "he correct answer is .! "his patient has a presentation that is most consistent with urinary tract infection &0"*)! "wo of the ma4or risk factors for uncomplicated 0"* are sexual intercourse and hypoestro$enism! )exual intercourse is belie ed to lead to urinary tract infection by introducin$ coloni2in$ bacteria into the bladder! )exual intercourse has been shown to increase the number of bacteria in the urine up to ten times! 'ypoestro$enism is belie ed to be a risk factor for 0"* because it is known that postmenopausal women not recei in$ estro$en replacement therapy &E?") are at $reater risk for de elopin$ a 0"* compared with those women who do use E?"! Durthermore3 estro$en administration has been shown to pre ent recurrent infection! .ardiac disease &choice A) is a ma4or risk factor for a number of conditions! 'owe er3 cardiac disease is not a known risk factor for 0"*! .ranberry 4uice in$estion &choice B) has3 for many years3 been belie ed to help pre ent 0"*s! 9any in the medical establishment iewed this as an 5old wi es tale!5 'owe er3 there ha e been many studies that ha e shown that cranberry 4uice contains substances that inhibit bacterial adherence! 9oreo er3 a recent study showed that elderly women that drank cranberry 4uice ha e lower rates of pyuria and bacteriuria and a decreased need for antibiotics! Cephrolithiasis &choice /) can be a risk factor for the de elopment of an e entual infection3 but it is not as common a risk factor as is hypoestro$enism or sexual intercourse! Durthermore3 this patient has no e idence of nephrolithiasis3 which typically causes se ere to excruciatin$ episodes of pain! )exual intercourse &choice E)3 as noted abo e3 is a well-known risk factor for the de elopment of a 0"*! )exually acti e women with recurrent 0"*s may be treated with a sin$le dose of antibiotic prophylactically after intercourse! "his patient3 howe er3 has stated that she is not sexually acti e!

-------------------------------------------------------------------------------77) A 3A-year-old woman3 $ra ida 73 para 13 at 3;-weeks $estation comes to the physician for a prenatal isit! "he patient#s due date was determined by a 8-week ultrasound! 'er prenatal course has been unremarkable! )he has no complaints of contractions3 loss of fluid3 or bleedin$ from the a$ina3 and her baby is mo in$ well! Examination demonstrates a fetal heart rate of 1:; and a fundal hei$ht of 78 centimeters3 which is the same measurement as that determined = weeks a$o! "his patient#s fundal hei$ht measurement is most su$$esti e of which of the followin$A! *naccurate estimated date of deli ery &due date) B! *ntrauterine $rowth restriction .! Premature labor /! "win $estation E! 0terine cancer Explanation1 "he correct answer is B! Dundal hei$ht measurement is a portion of the physical examination that should be performed routinely durin$ prenatal care! *t is performed by placin$ a measurin$ tape on the pubic symphysis and measurin$ to the top of the fundus! Between the $estational a$es of 18 to 3= weeks3 there is a rou$h correlation between weeks of $estation and fundal hei$ht in centimeters! Dor example3 a woman at 7> weeks# $estation should ha e a fundal hei$ht that is rou$hly 7> centimeters! "his patient is at 3; weeks# $estation and has a fundal hei$ht of 78 centimeters! Durthermore3 and perhaps more importantly3 there has been no chan$e in the fundal hei$ht o er the past four weeks! "hese findin$s are concernin$ for intrauterine $rowth restriction &*0(?)! *0(? is a disorder in which the fetus is not $rowin$ appropriately! *t is most commonly defined as an estimated fetal wei$ht less than the 1;th percentile for a $i en $estational a$e! (i en that this patient#s fundal hei$ht does not appear to ha e increased o er the past = weeks and that it is 3 centimeters less than expected3 *0(? is of concern and this patient should be sent for an ultrasound to e aluate fetal si2e! "his patient is unlikely to ha e an inaccurate estimated date of deli ery &due date) &choice A) because her due date was determined by a 8-week ultrasound! 0ltrasound datin$ of a pre$nancy is more accurate the earlier in pre$nancy that it is performed and a 8-week ultrasound is considered excellent for establishin$ a due date! Premature labor &choice .) would not be a concern in this patient with no contractions and no other symptoms! A twin $estation &choice /) should ha e been seen on the 8-week ultrasound! Durthermore3 a fundal hei$ht that is less than the $estational a$e would predict makes twins less likely! 0terine cancer &choice E) is ery uncommon durin$ pre$nancy and would not be expected to present as decreased fundal hei$ht! -------------------------------------------------------------------------------73) A 33-year-old woman3 $ra ida 33 para 33 comes to the physician for an annual examination! )he has no complaints! Past medical history is si$nificant for two episodes of .hlamydia and one episode of $onorrhea! Bbstetric history is si$nificant for three normal spontaneous a$inal deli eries with $estational diabetes durin$ the last two pre$nancies! )he takes no medications! Damily history is si$nificant for paternal coronary

artery disease! Physical examination is unremarkable! ,hich of the followin$ inter entions should this patient most likely ha eA! .hest x-ray e ery 3 years B! .oronary an$io$raphy e ery 3 years .! Dastin$ $lucose testin$ e ery 3 years /! 9ammo$raphy e ery 3 years E! Pap testin$ e ery 3 years Explanation1 "he correct answer is .! Patients with a history of $estational diabetes ha e a hi$h likelihood for e entually de elopin$ o ert diabetes! "hese women should therefore be extensi ely counseled re$ardin$ the importance of diet and exercise! Alon$ with counselin$3 testin$ is necessary to determine which patients actually do de elop o ert diabetes! "estin$ should be performed in the first few months followin$ the deli ery! "his testin$ may be a 8:-$3 7hour3 oral $lucose tolerance test! /iabetes is dia$nosed if the fastin$ $lucose le el exceeds 1=; m$Ed+3 or two post-$lucose measurements exceed 7;; m$Ed+! Patients should then under$o fastin$ $lucose testin$ e ery 3 years! "his patient3 $i en her history of $estational diabetes3 needs to ha e re$ular testin$! .hest x-ray e ery 3 years &choice A) is not recommended as a screenin$ test for this patient! Althou$h the number of deaths from lun$ cancer surpasses that of breast cancer3 and lun$ cancer is the leadin$ cause of cancer death in women3 routine chest x-ray is not used as a re$ular screenin$ test! .oronary an$io$raphy e ery 3 years &choice B) would not be recommended for this patient! "his is an in asi e procedure that currently is not used as a re$ular screenin$ test in the $eneral population! 9ammo$raphy e ery 3 years &choice /) would not be recommended for this patient! At 33 years of a$e3 she does not yet re%uire routine mammo$raphy! )he should ha e a mammo$ram e ery 1-7 years startin$ at a$e =;3 and then annually startin$ at a$e :;! Pap testin$ e ery 3 years &choice E) would not be recommended for this patient! Pap testin$ should be performed annually startin$ at a$e 183 or with the initiation of sexual intercourse! )ome recommend that the inter al can be increased at the physician#s discretion in a low-risk patient with three normal Pap tests in a row! Bthers dispute this3 ar$uin$ that annual Pap tests should be performed on all women! *n any e ent3 this patient3 with her history of .hlamydia and $onorrhea3 is not low risk and therefore needs annual Pap testin$! -------------------------------------------------------------------------------7=) A =;-year-old woman comes to the physician for an annual examination! )he has no complaints! )he has menses e ery 78-3; days that last for 3 days! )he has no intermenstrual bleedin$! )he has asthma3 for which she uses an occasional inhaler! )he had a tubal li$ation 1; years a$o! )he has no known dru$ aller$ies! Examination is unremarkable3 includin$ a normal pel ic examination! Bne of her friends was recently dia$nosed with endometrial cancer3 and the patient wants to know when and if she needs to be screened for this! ,hich of the followin$ is the most appropriate responseA! )creenin$ for endometrial cancer is not cost effecti e or warranted B! )creenin$ is with endometrial biopsy and starts at a$e =; .! )creenin$ is with endometrial biopsy and starts at a$e :;

/! )creenin$ is with ultrasound and starts at a$e =; E! )creenin$ is with ultrasound and starts at a$e :; Explanation1 "he correct answer is A! Endometrial cancer is the most common $ynecolo$ic cancer in women older than =:! "here are tens of thousands of new cases e ery year in the 0!)!3 and thousands of deaths from it yearly! 'owe er3 there is no effecti e screenin$ test for endometrial cancer at this point! *t is not cost-effecti e to screen asymptomatic women for endometrial cancer! Bccasionally3 a Pap test will detect abnormal endometrial cells3 but it is not a proper screenin$ tool for endometrial cancer! Patients with endometrial hyperplasia or cancer often present with irre$ular uterine bleedin$! "herefore3 patients with irre$ular uterine bleedin$ should be considered for endometrial biopsy or ultrasonic e aluation of the endometrial ca ity! "his strate$y may be modified for youn$ patients3 in whom the risk of endometrial hyperplasia or cancer is limited! "o state that screenin$ is with endometrial biopsy and starts at a$e =; &choice B) or a$e :; &choice .) is incorrect! Endometrial biopsy can and should be used in certain circumstances! Dor example3 a woman with postmenopausal bleedin$ should under$o the procedure! 'owe er3 endometrial biopsy should not be used as a screenin$ tool! "o perform endometrial biopsies on women with no indication other than screenin$ would place these women at risk for bleedin$3 infection3 and uterine perforation3 and would not be cost-effecti e! "o state that screenin$ is with ultrasound and starts at a$e =; &choice /) or a$e :; &choice E) is incorrect! Pel ic ultrasound can be used to help dia$nose endometrial hyperplasia and endometrial cancer! Dor example3 studies ha e shown that in postmenopausal women3 measurement of the endometrial stripe can be useful in helpin$ to rule out these conditions! 'owe er3 pel ic ultrasound has not been shown to be cost-effecti e or warranted for screenin$ for endometrial cancer! -------------------------------------------------------------------------------7:) A :3-year-old woman comes to the physician for an annual examination! )he has no complaints! )he has hypertension3 for which she takes a thia2ide diuretic3 but no other medical problems! 'er past $ynecolo$ic history is si$nificant for normal annual Pap tests for many years3 her last bein$ 7 months a$o! A recent mammo$ram was ne$ati e! 'eart3 lun$3 breast3 abdomen3 and pel ic examination are unremarkable! ,hich of the followin$ procedures or tests should most likely be performed on this patientA! .hest x-ray B! Pap test .! Pel ic ultrasound /! Prostate-specific anti$en &P)A) E! ?ectal examination Explanation1 "he correct answer is E! .ancer screenin$ should be an essential part of an annual examination! .olorectal cancer is a ma4or cause of serious morbidity and mortality for women in the 0!)!1 $reater than :;3;;; new cases are dia$nosed each year3 and there are more than 7:3;;; deaths from colorectal cancer! )creenin$ should be$in at a$e :; in asymptomatic women with

no si$nificant family history! )creenin$ consists of a di$ital rectal examination with fecal occult blood testin$! "his can be performed at the same time that pel ic examination is performed! )i$moidoscopy should be performed e ery 3-: years! "his patient has no indication for a chest x-ray &choice A)! +un$ cancer has surpassed breast cancer as the ma4or cause of cancer death in women! 'owe er3 chest x-ray films are not used for lun$ cancer screenin$! "here is currently no techni%ue a ailable for routine screenin$ for lun$ cancer! "he Pap test &choice B) is an important method of screenin$ for cer ical cancer and should be performed annually! 'owe er3 this patient had a normal Pap test 7 months a$o! Pel ic ultrasound &choice .) is not indicated in this patient! )he has nothin$ abnormal in her history or physical that would warrant pel ic ultrasound! Pel ic ultrasound is not used for cancer screenin$! Prostate-specific anti$en &P)A) &choice /) is an appropriate test in men! P)A testin$ would not be indicated in this &female) patient! -------------------------------------------------------------------------------7>) A 71-year-old woman3 $ra ida 73 para 13 at 77 weeks# $estation comes to the physician because of a malodorous a$inal dischar$e! )he states that she first noticed the dischar$e 7 days a$o and since then it has become more profuse and malodorous! 'er prenatal course has been unremarkable durin$ this pre$nancy! 'er prior pre$nancy was complicated by preterm labor and deli ery at 31 weeks# $estation! Examination shows a $rayish a$inal dischar$e! A stron$ amine odor is released when IB' is applied to a sample of the dischar$e! Examination of a normal saline &5wet5) preparation re eals numerous 5clue5 cells! ,hich of the followin$ is the most appropriate pharmacotherapyA! Co treatment is needed B! Bral metronida2ole .! *ntramuscular penicillin /! *@ penicillin E! Bral penicillin Explanation1 "he correct answer is B! "his patient has si$ns and symptoms that are most consistent with bacterial a$inosis! Bacterial a$inosis represents a chan$e in milieu of the a$ina such that there is a decrease in the number of lactobacilli and an increase in anaerobic or$anisms! Patients with bacterial a$inosis usually complain of a malodorous a$inal dischar$e! "he examination is si$nificant for a $rayish dischar$e that releases a stron$ amine &or fishy) odor when IB' is applied to it! "his is known as a positi e 5whiff5 test! 9icroscopic examination re eals clue cells3 which are a$inal epithelial cells that are co ered with bacteria! )tudies ha e demonstrated an association between bacterial a$inosis and preterm deli ery! "here is some e idence that treatment of bacterial a$inosis with oral metronida2ole in women at hi$h risk for preterm deli ery Ki!e!3 women with a prior preterm deli ery or a low prepre$nancy wei$ht &F:;k$)L will help to pre ent preterm deli ery! Bral metronida2ole appears to be better than the topical3 a$inal formulation for the pre ention of preterm deli ery! "o state that no treatment is needed &choice A) is incorrect! Dirst3 this patient is symptomatic6 therefore3 treatment is reasonable! )econd3 treatment of bacterial a$inosis in the second trimester in women at hi$h risk for preterm deli ery may pre ent a preterm deli ery! *ntramuscular penicillin &choice .) is used

durin$ pre$nancy for women with syphilis! *t is not used to treat bacterial a$inosis! *@ penicillin &choice /) is used durin$ labor to pre ent neonatal $roup B )treptococcus infection! *t is not used for bacterial a$inosis! Bral penicillin &choice E)3 like intramuscular and *@ penicillin3 is used for $ram-positi e infections! Patients with bacterial a$inosis re%uire treatment with a dru$ that will co er anaerobic infections &e!$!3 metronida2ole!) -------------------------------------------------------------------------------78) A 73-year-old woman comes to the physician because she thinks that she may be pre$nant! )he missed her last two periods and feels 5different!5 A urine pre$nancy test is positi e and an ultrasound re eals a 17-week fetus! "he patient is ery concerned because she recei ed the measles-mumps-rubella &99?) accine four months a$o and was told to wait 3 months before attemptin$ conception! "he pre$nancy is desired! "he patient asks if she should ha e a termination of pre$nancy because she was accinated shortly before becomin$ pre$nant! ,hich of the followin$ is the most appropriate responseA! "here is no accine risk and termination is completely inappropriate B! "he accine risk is low and is not in itself a reason to terminate .! "he accine risk is moderate and termination should be considered /! "he accine risk is hi$h and termination should be stron$ly considered E! "he accine risk is hi$h and termination is mandated Explanation1 "he correct answer is B! ,omen that ac%uire rubella durin$ pre$nancy are at risk of de elopin$ fetal infection and con$enital rubella syndrome! *f the mother is infected durin$ the first trimester the malformation rate in the fetus is approximately :;<! "hese malformations include microcephaly3 mental retardation3 cataracts3 deafness3 and con$enital heart diseasealthou$h all or$ans may be affected! "herefore3 all women need to be accinated with the rubella accine-most often $i en as part of the 99? series of accines! 'owe er3 because the 99? accine is a li e- irus accine3 there is a concern that administration of the accine within 3 months of conception3 or durin$ the pre$nancy3 could result in birth defects or illness! Met3 this concern is more theoretical than real as studies performed on women $i en the rubella accine shortly before becomin$ pre$nant or durin$ pre$nancy ha e failed to show any increase in the risk of malformations compared to the $eneral back$round risk in the population! "he current 0) immuni2ation policy is that the risk of accine-associated defects is irtually ne$li$ible and should not be a reason in itself to consider termination! "o state that there is no accine risk and termination is completely inappropriate &choice A) is incorrect! Althou$h the risk of the 99? accine appears more theoretical than real3 one cannot state that there is no risk! "o state that the accine risk is moderate and termination should be considered &choice .) or that the accine risk is hi$h and termination should be stron$ly considered &choice /) is incorrect! As stated abo e3 the risk of the 99? accine-associated defects is so small as to be considered ne$li$ible! "o state that the accine risk is hi$h and termination is mandated &choice E) is absolutely incorrect! Dirst3 the accine risk is not hi$h! )econd3 e en if the fetus were found to ha e se ere defects3 it is the patient#s choice whether or not to keep the pre$nancy!

-------------------------------------------------------------------------------78) A 77-year-old woman comes to the physician because of a missed menstrual period! )he has a complex past medical history! )he has hypothyroidism3 for which she takes thyroxine3 she has an artificial heart al e3 for which she takes .oumadin3 and she recently started tetracycline for acne! )he does not think that she is pre$nant because she is currently on the oral contracepti e pill3 but3 if pre$nant3 she would keep the pre$nancy! Physical examination3 includin$ pel ic examination3 is unremarkable! 0rine human chorionic $onadotropin &h.() is positi e! ,hich of the followin$ medications should the patient continue to take durin$ the pre$nancyA! .oumadin B! Bral contracepti e pill &B.P) .! "etracycline /! "hyroxine E! /iscontinue all medications Explanation1 "he correct answer is /! 'ypothyroidism is associated with se eral complications re$ardin$ fertility and pre$nancy! ,omen with o ert hypothyroidism ha e increased rates of infertility! ,omen with uncorrected hypothyroidism that do become pre$nant are at increased risk of ha in$ stillborn and low-birth-wei$ht infants! @arious studies ha e also shown that rates of preeclampsia3 placental abruption3 and heart failure may be increased in pre$nant patients with hypothyroidism! Pre$nancy often leads to an increased re%uirement for thyroid hormone replacement &thyroxine) as the pre$nancy pro$resses! Pre$nant women with hypothyroidism on thyroxine should ha e their thyroid stimulatin$ hormone &")') le el checked periodically to determine if the dru$ dosa$e is ade%uate! "his patient3 with her history of hypothyroidism3 should continue her thyroxine durin$ the pre$nancy! .oumadin &choice A) is contraindicated durin$ pre$nancy3 as it is a known cause of birth defects! "his patient needs anticoa$ulation3 howe er3 and should be placed on heparin3 which does not cross the placenta! *t is possible to become pre$nant while takin$ the oral contracepti e pill &choice B)3 as the pill has a small rate of failure! "here is no known association between first trimester exposure and birth defects! Cow that the patient has become pre$nant3 howe er3 she should stop takin$ the B.P! "etracycline &choice .) is used to treat some forms of acne and3 therefore3 some women will become pre$nant while on the medication! *ts use is contraindicated durin$ pre$nancy3 howe er3 because it is associated with fetal teeth and bone malformations! "o state that the patient should discontinue all medications &choice E) is absolutely incorrect! ,hile some medications are contraindicated durin$ pre$nancy3 many are necessary and should be continued! -------------------------------------------------------------------------------7A) A 1A-year-old nulli$ra id woman comes to the emer$ency department because of se ere left lower %uadrant pain! )he has been noticin$ this pain intermittently for the past 3 days3 but this afternoon it became persistent and se ere and was accompanied by nausea and omitin$! Examination shows left lower %uadrant tenderness and a tender left adnexal mass! 0rine h.( is ne$ati e! Pel ic ultrasound shows a 8 cm left o arian

complex mass! ,hich of the followin$ is the most appropriate next step in mana$ementA! Expectant mana$ement B! Dollow-up ultrasound in > weeks .! *ntra enous antibiotics /! +aparoscopy E! Bophorectomy Explanation1 "he correct answer is /! B arian torsion is a sur$ical emer$ency! B arian torsion occurs when the o ary completely twists and thus3 occludes its blood supply! Patients often present with intermittent pain as the o ary twists and untwists and then constant3 se ere pain when the torsion becomes complete and the o ary becomes ischemic! "ime is of the essence and can mean the difference between sa in$3 ersus losin$3 an o ary! "his is important for any patient3 but is particularly important for a youn$ female of childbearin$ a$e3 especially one who is nulli$ra id! "he reason that time is so essential is that the lon$er the o ary stays torsed3 the more likely it is to become necrotic! 9ost sur$eons would perform laparoscopy on this patient if they felt it was safe to do so! "he pel is can be fully e aluated throu$h the laparoscope and a torsion can often be untwisted usin$ laparoscopic instruments! 'owe er3 with lar$e cysts3 some sur$eons prefer to perform a laparotomy! Expectant mana$ement &choice A) would not be appropriate for this patient! ,hen o arian torsion is considered to be likely in a patient3 that patient must ha e sur$ery! "o expectantly mana$e these patients is to risk further dama$e to3 and possible loss of3 the o ary! A follow-up ultrasound in > weeks &choice B) is appropriate mana$ement for some o arian cysts! Dor example3 if this patient were asymptomatic and the cyst did not ha e features suspicious for mali$nancy3 one could follow-up with an ultrasound in > weeks3 as lon$ as the patient was $i en strict instructions and precautions re$ardin$ the risk of torsion! 'owe er3 this patient has se ere pain and may be infarctin$ her o ary and therefore needs sur$ery! *ntra enous antibiotics &choice .) would be appropriate if the patient had pel ic inflammatory disease or another infectious process3 howe er3 the likely dia$nosis is torsion3 and sur$ery3 rather than intra enous antibiotics3 is needed! *n the past3 oophorectomy &choice E) was recommended for any patient with o arian torsion! "he concern was that the torsion would lead to thrombus formation in the o arian essels and that detorsin$ the o ary could lead to thromboembolism to the pulmonary asculature! .urrent thinkin$ is that the o ary may be detorsed and then e aluated! *f the o ary appears to be iable3 it may be left in-situ! *f the o ary appears to be completely non- iable and necrotic3 it will be remo ed! -------------------------------------------------------------------------------3;) A 7>-year-old primi$ra id woman at 17 weeks# $estation comes to the physician because of pain and swellin$ in her ri$ht thi$h! )he first noted the onset of the pain 7 days a$o3 and since then it has $rown worse! An ultrasound study performed on her lower-extremity enous system re eals e idence of a proximal thrombus in the ri$ht le$! )he is started on low-molecular-wei$ht heparin in4ections! ,hich of the followin$ is an ad anta$e of low-molecular-wei$ht heparin compared with unfractionated heparinA! +ow-molecular-wei$ht heparin has a shorter half-life

B! +ow-molecular-wei$ht heparin is cheaper .! +ow-molecular-wei$ht heparin is less likely to cause birth defects /! +ow-molecular-wei$ht heparin is less likely to cause thrombocytopenia E! +ow-molecular-wei$ht heparin is less likely to cross the placenta Explanation1 "he correct answer is /! "his patient has a deep enous thrombosis &/@") in her ri$ht lower extremity! Pre$nancy is a risk factor for the de elopment of /@"s because of alterations in coa$ulation factors3 enous stasis3 and3 often3 decreased physical acti ity! *t is essential that /@" durin$ pre$nancy be treated so that the thrombus does not proliferate or emboli2e and so that new thrombi do not form! .oumadin is contraindicated durin$ the first trimester because of the risk of birth defects in fetuses exposed to this dru$! .oumadin embryopathy is a syndrome consistin$ of nasal hypoplasia and stippled ertebral and femoral epiphyses! )econd- and third-trimester exposure to .oumadin can lead to hydrocephaly3 microcephaly3 ophthalmolo$ic abnormalities3 fetal $rowth retardation3 and de elopmental delay! +ow-molecular-wei$ht heparin has been shown to be an excellent anticoa$ulant because it has a lon$er half-life and a more predictable dose-response relationship compared with unfractionated heparin3 which allows once- or twice-daily dosin$ without the need for fre%uent laboratory monitorin$ of the prothrombin time and acti ated partial thromboplastin time! +ow-molecular-wei$ht heparin is also less likely to cause thrombocytopenia and hemorrha$ic complications than unfractionated heparin! +ow-molecular-wei$ht heparin does not ha e a shorter half-life &choice A) than unfractionated heparin! *n fact3 low-molecular-wei$ht heparin has a lon$er half-life3 and it is this %uality that allows for once- or twice-daily dosin$! +owmolecular-wei$ht heparin is not cheaper &choice B) than unfractionated heparin! +owmolecular-wei$ht heparin itself is more expensi e3 but there is a cost ad anta$e in that less fre%uent laboratory monitorin$ is needed! Ceither low-molecular-wei$ht heparin nor unfractionated heparin is likely to cause birth defects &choice .)! Ceither crosses the placenta &choice E) and neither is associated with terato$enesis! -------------------------------------------------------------------------------31) A 7A-year-old female comes to the physician because of fe ers and back pain! )he is otherwise healthy with no si$nificant past medical history! Examination is si$nificant for a temperature of 38!3 . &1;1 D)3 moderate costo ertebral an$le tenderness3 leukocytosis3 and white blood cells and red blood cells in the urine! "he patients is dia$nosed with pyelonephritis and started on intra enous antibiotics! B er the next two days3 she rapidly impro es3 and by hospital day 33 she is toleratin$ oral intake3 oidin$ without difficulty3 feelin$ no pain3 and she has not had a fe er for =8 hours! ,hich of the followin$ is the most appropriate next step in mana$ementA! .ontinue intra enous antibiotics for 7 weeks B! /ischar$e home and recommend post-coital prophylaxis .! /ischar$e home off all antibiotics /! /ischar$e home to complete a 7-week course of oral antibiotics E! Bbtain sur$ical e aluation Explanation1

"he correct answer is /! "his patient has had an uncomplicated course of pyelonephritis thus far! Pyelonephritis is an infection of the kidney! Patients with pyelonephritis typically present with some combination of back pain3 dysuria3 hematuria3 fre%uency3 ur$ency3 fe ers3 chills3 nausea3 and omitin$! Examination often shows an ele ated temperature3 costo ertebral an$le tenderness3 leukocytosis3 and white cells and red cells in the urine! .ompletely uncomplicated cases of pyelonephritis can be treated on an outpatient basis! ,hen there are any complicatin$ factors &e!$!3 concern for sepsis3 pre$nancy3 old a$e3 or other medical illnesses)3 the patient should be admitted to the hospital for intra enous antibiotics! 'owe er3 once the patient#s condition has impro ed and she is toleratin$ oral intake3 she may be dischar$ed home to complete a 7-week course of antibiotics! ,hen dischar$ed3 howe er3 she should be $i en strict instructions and precautions re$ardin$ the need to return for recurrence of the symptoms or worsenin$ condition! "o continue intra enous antibiotics for 7 weeks &choice A) would not be necessary! Bnce a patient with pyelonephritis is afebrile3 doin$ better3 and able to tolerate oral intake3 she may be con erted to oral antibiotics and be dischar$ed to home! "o keep the patient hospitali2ed for a full 7 weeks would not be necessary! "o dischar$e home and recommend post-coital prophylaxis &choice B) or to dischar$e home off all antibiotics &choice .) would not be correct! E en thou$h the patient is feelin$ better3 she must still complete a 7-week course of oral antibiotics and not 4ust use antibiotics for post-coital prophylaxis! "o obtain sur$ical e aluation &choice E) would not be necessary! *f a patient with pyelonephritis is not impro in$3 then sur$ical e aluation may be re%uired to determine if another etiolo$y is responsible or to determine if sur$ical inter ention is re%uired! "his patient3 howe er3 is impro in$ and sur$ical e aluation would not be necessary! -------------------------------------------------------------------------------37) A 3>-year-old woman3 $ra ida :3 para =3 at 3; weeks# $estation comes to the physician for a prenatal isit! )he feels the baby mo in$ and has not had bleedin$ per a$ina3 contractions3 or loss of fluid! "he prenatal course has been uncomplicated thus far! "he patient is interested in ha in$ a postpartum tubal li$ation! )he has many %uestions re$ardin$ the procedure3 includin$ whether there is a risk of failure! ,hich of the followin$ represents the closest estimate for the likelihood of failure of a postpartum tubal li$ationA! 1 in 1; B! 1 in 1;; .! 1 in 1;;; /! 1 in 13;;;3;;; E! "here are no reported failures of postpartum tubal li$ation! Explanation1 "he correct answer is B! Postpartum tubal li$ation is a hi$hly effecti e method for $i in$ a woman permanent sterili2ation! 9any methods ha e been de eloped3 but the most common methods in ol e doubly li$atin$ a portion of each tube and excisin$ an inter enin$ se$ment! A postpartum tubal li$ation can be performed at the time of cesarean deli ery or after a a$inal deli ery! *f the procedure is performed after a a$inal deli ery3 a relati ely small skin

incision is usually made in or near the umbilicus! Patients under$oin$ postpartum tubal li$ation should be warned3 howe er3 that the procedure could fail! Dailure may result from many factors includin$ recannali2ation of the tube and poor sur$ical techni%ue! "he most commonly %uoted failure rate is about 1 in 1;;3 althou$h a more accurate fi$ure may be closer to 1 in 3;;! 'owe er3 it is impossible to $i e one exact rate3 because the risk of failure depends on the patient#s a$e! A 7:-year-old woman under$oin$ tubal li$ation is more likely to experience failure than a =;-year-old woman3 because the 7:year-old has so many more years of fertility ahead of her! *f the failure rate were 1 in 1; &choice A) few doctors would recommend the procedure! Dor a birth control method to be useful3 it must ha e a low o erall failure rate! A failure rate of 1;< would be too $reat to 4ustify the risk of the procedure! 1 in 1;;; &choice .) or 1 in 13;;;3;;; &choice /) are the failure rates that obstetricians would like to see from tubal li$ation! Perhaps with time and chan$es in methodolo$y3 the failure rates will continue to fall! At present3 howe er3 the most commonly %uoted failure rate is 1 in 1;;! "o state that there are no reported failures of postpartum tubal li$ation &choice E) is absolutely incorrect! Patients need to be cautioned that the procedure can fail and that if pre$nancy is suspected3 they should notify their doctor immediately3 as the risk of ectopic pre$nancy after tubal li$ation is si$nificant! -------------------------------------------------------------------------------33) A 77-year-old woman3 $ra ida 73 para ;3 at 8 weeks# $estation comes to the physician for a prenatal isit! )he has no complaints! 'er first pre$nancy resulted in a 77-week loss when she presented to her physician with bleedin$ from the a$ina3 was found to be fully dilated3 and deli ered the fetus! Examination of the patient today is unremarkable! )he declines to ha e a cercla$e placed! ,hen should this patient be$in ha in$ re$ular cer ical examinationsA! 1; weeks B! 1> weeks .! 77 weeks /! 78 weeks E! 38 weeks Explanation1 "he correct answer is B! "his patient has an obstetrical history that is consistent with abnormal cer ical competence! "his dia$nosis may be made when the patient has a history of painless cer ical dilation in the second trimester! .er ical incompetence is a cause of secondtrimester pre$nancy loss and preterm deli ery! .er ical incompetence may be con$enital andEor ac%uired! ,omen who ha e had pre ious trauma to the cer ix &e!$! dilation of the cer ix3 cer ical coni2ation3 or obstetric trauma) and women with mullerian anomalies3 or a history of in-utero exposure to diethylstilbestrol may be at increased risk! "his patient3 $i en her history3 was offered a cercla$e! .ercla$e is a procedure in which a suture is placed at the le el of the internal os after bladder dissection &)hirodkar) or as hi$h up on the cer ix as possible &9c/onald)! A prophylactic cercla$e is placed between 17 and 1> weeks# $estation! Bnce the cercla$e is placed3 the patient should not en$a$e in sexual intercourse3 prolon$ed standin$3 or hea y liftin$! "his patient3 howe er3 refused to ha e a

cercla$e placed! (i en her history3 howe er3 she needs to be followed closely to ensure that any si$ns of cer ical incompetence are detected as soon as possible! ?e$ular examinations of the cer ix3 either di$itally or with ultrasound3 should be$in at 1> weeks because cer ical incompetence becomes a concern durin$ the second trimester! )tartin$ re$ular examinations at 1; weeks &choice A) is unlikely to be helpful! .er ical incompetence most often manifests itself in the second or third trimester! )tartin$ re$ular examinations at 77 weeks &choice .) or 78 weeks &choice /) would not be correct3 as these $estational a$es may be too late to detect cer ical chan$es! "his patient lost her last pre$nancy at 77 weeks3 which means that her cer ix may ha e started chan$in$ se eral weeks earlier! "o wait until 77 or 78 weeks would risk missin$ cer ical chan$es and the possibility of institutin$ chan$es &e!$!3 bed rest3 hospitali2ation3 or cercla$e placement) to help pre ent pre$nancy loss! 38 weeks &choice E) is the time at which a cercla$e should be remo ed! *n a woman with a history of a 77-week loss3 waitin$ until 38 weeks to start checkin$ the cer ix re$ularly would not be appropriate! -------------------------------------------------------------------------------3=) A 1A-year-old female comes to the physician because she has not had a menstrual period! )he experienced normal breast de elopment throu$h puberty but has yet to ha e a period! )he has no other complaints! )he has no medical problems! Examination shows the patient to be tall with lon$ arms and bi$ hands! "he breasts are normal-appearin$ except that the nipples are immature and the areolae are pale! Pel ic examination shows scant pubic hair with a blind-ended a$inal pouch! ,hich of the followin$ is the most likely dia$nosisA! Asherman syndrome B! Iallmann syndrome .! Polycystic o arian syndrome /! "esticular femini2ation syndrome E! "urner syndrome Explanation1 "he correct answer is /! "his patient has a presentation and findin$s that are most consistent with andro$en insensiti ity syndrome &also called testicular femini2ation syndrome)! "hese patients are $enotypically male &=>3 NM) but phenotypically female because they ha e a defect that pre ents normal andro$en receptor function! "he andro$en receptor $ene is located on the N chromosome and arious defects in the $ene &e!$!3 absence of the $ene or abnormalities in the andro$en bindin$ domain of the receptor) can lead to this syndrome! Patients with andro$en insensiti ity are amenorrheic and ha e no internal female structures! "estes rather than o aries are present! "hese patients also ha e minimal axillary and pubic hair! "hey do experience abundant breast de elopment at puberty3 as testosterone is unable to suppress the formation of breast tissues! "hese patients also tend to be ery tall with bi$ hands and feet and lon$ arms! "estes should be remo ed after pubertal de elopment is completed3 as many of these patients will de elop $onadal mali$nancies after puberty! Asherman syndrome &choice A) is amenorrhea caused by intrauterine adhesions! "hese adhesions typically de elop after curetta$e and infection of the uterus! Iallmann syndrome &choice B) is amenorrhea caused by hypo$onadotropic hypo$onadism! *t is

associated with anosmia3 color blindness3 and facial deformities! Patients ha e normal female structures! Patients with polycystic o arian syndrome &choice .) usually ha e the characteristics of oli$omenorrhea3 hirsutism3 infertility3 and obesity! "his patient has none of these characteristics! Patients with "urner syndrome &choice E) ha e a =:3 N $enotype! "hey are phenotypically females3 often with small stature3 short necks3 and wide chests! "his patient has a eunuchoid phenotype! -------------------------------------------------------------------------------3:) A :3-year-old woman comes to the physician because of concerns re$ardin$ menopause! )he has a period almost e ery month3 but her cycle is len$thenin$! )he is worried because her mother3 her two older sisters3 and practically all her aunts ha e osteoporosis! )he does not want to be on estro$en because she is concerned about cancer and thrombosis! Physical examination is within normal limits! "he patient is started on raloxifene! Bn this medication3 which of the followin$ is this patient most likely to de elopA! Breast cancer B! Ele ated cholesterol .! Endometrial hyperplasia /! 'ot flashes E! Bsteoporosis Explanation1 "he correct answer is /! ?aloxifene is a medication that belon$s to the class of dru$s called selecti e estro$en receptor modulators &)E?9s)! "hese dru$s3 of which the most widely known are raloxifene and tamoxifen3 ha e pro-estro$enic effects in some tissues and anti-estro$enic effects in other tissues! ?aloxifene has been appro ed by the 0!)! Dood and /ru$ Administration for the pre ention of osteoporosis! "his patient3 with her stron$ family history of osteoporosis3 is a $ood candidate for pre ention! 'owe er3 althou$h raloxifene acts as an estro$en a$onist in the bone3 it appears to ha e no effect on hot flashes or to actually cause hot flashes! "herefore3 this perimenopausal patient is most likely to de elop hot flashes while on raloxifene! Althou$h definiti e proof is not a ailable3 it appears that raloxifene acts as an estro$en anta$onist in the breast! "herefore3 this patient would not be most likely to de elop breast cancer &choice A) while on raloxifene! )he would be more likely to de elop hot flashes! ?aloxifene appears to lower cholesterol3 especially +/+ cholesterol3 in patients! "herefore3 ele ated cholesterol &choice B) would be less likely while on this medication! ?aloxifene appears to act as an estro$en anta$onist at the le el of the endometrium6 therefore3 endometrial hyperplasia &choice .) would be less likely than hot flashes! ?aloxifene is used in the pre ention of osteoporosis &choice E)! -------------------------------------------------------------------------------3>) A =8-year-old woman comes to the physician for an annual examination! Bne year a$o3 she was dia$nosed with endometrial carcinoma and underwent a total abdominal hysterectomy and bilateral salpin$o-oophorectomy! )he was found to ha e $rade *3 sta$e

*3 disease at that time! B er the past year3 she has de eloped se ere hot flashes that occur throu$hout the day and ni$ht and are worsenin$! )he is also concerned because her mother and se eral of her aunts ha e se ere osteoporosis! )he wonders whether she can take estro$en replacement therapy! ,hich of the followin$ is the most appropriate responseA! Estro$en replacement therapy is absolutely contraindicated B! Estro$en replacement therapy may be used3 and there are no risks .! Estro$en replacement therapy may be used3 but there are risks /! Estro$en replacement therapy will lead to breast cancer E! Estro$en replacement therapy will lead to cancer recurrence Explanation1 "he correct answer is .! "he issue of whether a patient who had endometrial carcinoma can be placed on estro$en replacement therapy &E?") is somewhat contro ersial! *f the patient is completely free of tumor3 estro$en replacement therapy should not result in recurrence! And3 in this patient#s case3 it would be helpful for her hot flashes and osteoporosis! 'owe er3 if an estro$en-dependent neoplasm is still present somewhere in her body3 E?" may result in an earlier recurrence! )ta$e *3 $rade *3 endometrial cancer is the lowest $rade and lowest sta$e endometrial cancer! "he risk of persistent disease is less than :<! 9any $ynecolo$ic oncolo$ists would feel comfortable $i in$ E?" to this patient! 'owe er3 the patient must be fully informed re$ardin$ the benefits and risks of E?"! "hese risks include not only earlier recurrence3 but also the standard risks such as enous thrombosis! "o state that estro$en replacement therapy is absolutely contraindicated &choice A) is incorrect! As explained abo e3 E?" may be $i en to certain patients with a history of $rade *3 sta$e *3 endometrial carcinoma! "o state that estro$en replacement therapy may be used and there are no risks &choice B) is not appropriate! E en in women with no history of endometrial carcinoma3 there are risks to E?"! "he history of endometrial carcinoma adds a further risk for this patient! "o state that estro$en replacement therapy will lead to breast cancer &choice /) is incorrect! "here are a number of studies that show that E?" leads to increased rates of breast cancer! "here are also a number of studies that show no increased risk! "herefore3 to make the definiti e statement that E?" will lead to breast cancer is incorrect! As explained abo e3 to state that E?" will lead to cancer recurrence &choice E) is not correct! -------------------------------------------------------------------------------38) A 37-year-old woman3 $ra ida 33 para ;3 at 7A weeks# $estation comes to the physician for a prenatal isit! )he has no complaints! )he had a prophylactic cercla$e placed at 17 weeks# $estation because of her history of two consecuti e 7;-week losses! "hese spontaneous abortions were both characteri2ed by painless cer ical dilation3 with the membranes found bul$in$ into the a$ina on examination ! 0ltrasound now demonstrates her cer ix to be lon$ and closed with no e idence of funnelin$! ,hich of the followin$ is the most appropriate time to remo e the cercla$e from this patientA! 3;-37 weeks B! 37-3= weeks .! 3=-3> weeks

/! 3>-38 weeks E! 38-=; weeks Explanation1 "he correct answer is /! "his patient has a history that is classic for cer ical incompetence! .er ical incompetence is characteri2ed by painless cer ical dilation3 typically in the second or early third trimester! Patients will often ha e membranes bul$in$ into the a$ina! *n reality3 many patients will present with cer ical dilation3 but they will also ha e some crampin$ or contractions! "his can make distin$uishin$ preterm labor from cer ical incompetence difficult! Also3 cer ical incompetence often leads to bul$in$ membranes that then rupture! "his rupture of the membranes can also cause contractions and labor such that when the patient presents3 the dia$nosis of cer ical incompetence ersus preterm labor is clouded! 'owe er3 when the dia$nosis of cer ical incompetence is clear3 as it is in this patient3 many practitioners fa or placin$ a cercla$e &a stitch around the cer ix intended to support the pre$nancy)! "his cercla$e should be left in place throu$hout the pre$nancy! Bnly when the patient is at term &3>-38 weeks) should the cercla$e be remo ed! "o remo e the cercla$e at 3;-37 weeks &choice A)3 37-3= weeks &choice B)3 or 3=-3> weeks &choice .) places the patient at risk of iatro$enic prematurity! )ay3 for example3 that the cercla$e is remo ed at 33 weeks3 and the patient $oes into labor immediately thereafter and deli ers! "his would result in a 33-week newborn3 with risks of intra entricular hemorrha$e3 respiratory distress syndrome3 and necroti2in$ enterocolitis! "his outcome would ha e been a oided by lea in$ the stitch in until 3>-38 weeks! "o remo e the cercla$e at 38-=; weeks &choice E) runs the risk that the patient may $o into labor prior to remo al of the stitch! "he concern here is that with labor3 the stitch will cause a cer ical laceration! "herefore3 the stitch should be remo ed prior to the likely onset of labor3 but not so early so as to result in a premature newborn if the patient $oes into labor with remo al of the stitch! "hus3 3>-38 weeks is an ideal time for remo al of a cercla$e! -------------------------------------------------------------------------------38) A ::-year-old woman comes to the physician because of hot flashes! )he first noted them about A months a$o3 and since then they ha e been worsenin$! )he states that the flashes come on at arious times throu$hout the day3 but that they are especially intense at ni$ht! )he had her last menstrual period approximately : months a$o! 'er medical history is si$nificant for a pulmonary embolus at the a$e of 3> and se ere depression! )he takes fluoxetine for depression and has no aller$ies to medications but smokes one pack of ci$arettes per day! Physical examination is unremarkable3 includin$ a normal pel ic examination! ,hich of the followin$ is the most appropriate pharmacotherapy for this patientA! .lonidine B! Estro$en and pro$esterone .! Estro$en only /! (lucopha$e E! "amoxifen Explanation1

"he correct answer is A! "his patient has a presentation that is most consistent with perimenopausal hot flashes &or hot flushes as they are sometimes called)! "he exact pathophysiolo$y that underlies the hot flash is not known! 'owe er3 it is known that women at the menopause and men that under$o orchiectomies experience these symptoms! "herefore3 it is assumed that it is the remo al of normal le els of sex steroids from the circulation that results in the hot flash! "hese hot feelin$s are experienced as a flushin$ that can last from se eral seconds to many minutes! "he first-line treatment for most women is with hormone replacement therapy! 'owe er3 estro$en is contraindicated in this patient $i en her history of pulmonary embolus! "he fact that she is a current smoker also places her at $reater risk of de elopin$ a thrombus if she were to take hormones! Pro$estins alone ha e also been shown to relie e hot flashes6 howe er3 they may worsen depression and cause other mood chan$es in patients! "herefore an alternati e treatment is needed for her! .lonidine has been used with some success by many women for relief from hot flashes! *t is a blood pressure medication3 but it has been shown to be effecti e a$ainst hot flashes when used in low doses! Estro$en and pro$esterone &choice B) should not be used in this patient because of her history of a pulmonary embolus! .ombined hormone replacement therapy has been shown to increase the risk of clot formation in patients! ,ith her history and current smokin$3 this patient would be at a particularly increased risk! Estro$en only &choice .) would be contraindicated in this patient for two reasons! Dirst3 her uterus is still in place3 and unopposed estro$en would place her at $reater risk for endometrial hyperplasia and cancer! )econd3 estro$en would increase this patient#s risk of thrombus formation! (lucopha$e &choice /) is an oral hypo$lycemic medication used in patients with diabetes! *t is not known to be effecti e for the treatment of hot flashes! "amoxifen &choice E) actually causes hot flashes in many patients and is not used to treat them! -------------------------------------------------------------------------------3A) A 7=-year-old woman comes to the physician for an initial prenatal isit! 'er last menstrual period was 8 weeks a$o and a home urine pre$nancy test was positi e! )he has had no bleedin$ or abdominal pain! )he does complain of increased fati$ue lately and some mild nausea and omitin$! Examination is si$nificant for both a systolic and a diastolic cardiac murmur! "he uterus is 8 weeks# si2ed and nontender! ,hich of the followin$ findin$s is most su$$esti e of structural heart disease in this womanA! /iastolic murmur B! Enlar$ed uterus .! Dati$ue /! Causea and omitin$ E! )ystolic murmur Explanation1 "he correct answer is A! Pre$nancy brin$s about numerous3 normal physiolo$ic chan$es in the pre$nant woman! )ome of the most ob ious chan$es are those found in the cardio ascular system! Dor example3 cardiac output rises markedly in pre$nancy with increases up to :;< o er nonpre$nant le els! .ardiac murmurs are common in pre$nancy with as many as A;< of all pre$nant women ha in$ some de$ree of a systolic murmur! /iastolic murmurs are

different3 howe er! "he findin$ of a diastolic murmur in a pre$nant woman must be thorou$hly e aluated as this type of murmur is often related to important cardiac disease! Dor example3 mitral stenosis3 the most common rheumatic al ular lesion in pre$nancy3 is characteri2ed by a rumblin$ diastolic murmur! "herefore3 patients with diastolic murmurs should ha e an echocardio$raph and possible referral to a cardiolo$ist for further e aluation! An enlar$ed uterus &choice B) is a normal findin$ in a pre$nant woman! *t is important to examine the uterus for si2e at the first prenatal isit to ensure that the si2e correlates to the patient#s datin$ by last menstrual period! *f there is a discrepancy3 then the patient should be sent for an ultrasound to obtain correct datin$3 which is essential for the mana$ement of the pre$nancy! Dati$ue &choice .) and nausea and omitin$ &choice /) are ery common findin$s in the first trimester of pre$nancy! ,hile fati$ue can sometimes be a symptom of structural heart disease3 it is not nearly as concernin$ as the diastolic murmur in this patient! Causea and omitin$ is present in anywhere from :; to A;< of all pre$nant women! As noted abo e3 a systolic murmur &choice E) is a ery common findin$ durin$ pre$nancy! 0p to A;< of all pre$nant women will ha e such a murmur durin$ pre$nancy! As lon$ as the murmur is systolic3 no louder than ***E@* and there is no other symptomatolo$y3 the murmur can be considered to be beni$n! -------------------------------------------------------------------------------=;) A =7-year-old woman3 $ra ida 73 para 13 at 1; weeks# $estation comes to the physician for her first prenatal isit! )he has no complaints! )he has a history of "richomonas infection3 but no other medical problems! Examination is si$nificant for a 1;-week si2ed3 nontender uterus! /urin$ the speculum examination3 a Pap smear is performed and $onorrhea and .hlamydia screenin$ tests are taken! "he next day3 the $onorrhea test returns as positi e! ,hich of the followin$ is the most appropriate pharmacotherapyA! .eftriaxone B! .lindamycin .! /oxycycline /! +e ofloxacin E! 9etronida2ole Explanation1 "he correct answer is A!Ceisseria $onorrhoeae is a known cause of cer icitis and can also play a role in the pathophysiolo$y of pel ic inflammatory disease &P*/)! *n pre$nant women3 it is implicated as a cause of preterm birth and chorioamnionitis! *n past decades3 transmission of the $onococcus at birth from the mother to her infant led to eye infection &$onococcal ophthalmia neonatorum) and blindness in many neonates! 0ni ersal neonatal eye prophylaxis with an antibiotic ointment has reduced the rates of $onococcal ophthalmia neonatorum considerably! Any woman who is found to be infected with the $onococcus durin$ pre$nancy should be treated! "he treatment of choice is ceftriaxone3 which is $i en as a one-time intramuscular in4ection! .efixime can also be used as an oral3 onetime dose medication that is better tolerated by some! Patients who cannot tolerate cephalosporins can be treated with spectinomycin as a sin$le intramuscular dose! Any patient with $onorrhea should also be $i en antibiotics that will co er .hlamydia as well!

"hus3 this patient should be $i en not only ceftriaxone3 but a2ithromycin &or erythromycin or amoxicillin) as well! *t is also essential that the patient#s sexual partner or partners be treated and that a test of cure be performed approximately = weeks later to ensure that the or$anism has been eradicated! .lindamycin &choice B) does not pro ide ade%uate co era$e for $onorrhea and therefore would not be the most appropriate pharmacotherapy! /oxycycline &choice .) is often used to treat .hlamydia in nonpre$nant patients! *t should not be used durin$ pre$nancy because of the effects on fetal teeth and bones! +e ofloxacin &choice /) is contraindicated durin$ pre$nancy because of a possible link with arthropathies in the offsprin$ of women exposed to the dru$! 9etronida2ole &choice E) is used durin$ pre$nancy to treat bacterial a$inosis and "richomonas! .urrent recommendations are that it should not be used durin$ the first trimester! *t is not used to treat $onorrhea! -------------------------------------------------------------------------------=1) A :=-year-old woman comes to the physician because of hot flashes! )he states that her hot flashes ha e been steadily worsenin$ o er the past year since she had a total abdominal hysterectomy and bilateral salpin$o-oophorectomy for menometrorrha$ia! Patholo$y from the sur$ery showed low $rade endometrial hyperplasia! )he has no medical problems and takes no medications! 'er family history is unremarkable except for a stron$ family history of osteoporosis! )he states that the hot flashes ha e become absolutely debilitatin$ for her and she wants to take somethin$ that will $i e her the best chance of stoppin$ them! ,hich of the followin$ is the most appropriate pharmacotherapyA! Alpra2olam B! .lonidine .! Estro$en /! Bral contracepti e pill E! ?aloxifene Explanation1 "he correct answer is .! 9enopause can brin$ about a number of bothersome symptoms for patients! "hese include anxiety3 fati$ue3 depression3 headaches3 insomnia3 and dyspareunia! Perhaps the most common symptom is the hot flash3 which is an uncomfortable sensation of heat3 especially in the face and chest! "hese flashes can occur once in a while or se eral times each day! "here are many therapies a ailable for hot flashes3 but the most effecti e appears to be estro$en! Cumerous studies ha e shown estro$en replacement to be hi$hly effecti e in reducin$ central ner ous system symptoms such as hot flushes3 insomnia3 irritability3 anxiety3 and headaches! "his patient may also benefit from estro$en $i en her stron$ family history of osteoporosis3 as estro$en replacement has been shown to be beneficial in reducin$ bone loss in postmenopausal women! "he fact that this patient had endometrial hyperplasia does not pre ent her from takin$ estro$en replacement therapy! )he had hyperplasia3 not endometrial cancer! And3 e en in some cases of endometrial cancer3 some $ynecolo$ic oncolo$ists would ar$ue that once therapy has been $i en &i!e!3 hysterectomy and bilateral oophorectomy) and there is no e idence of residual disease3 then estro$en replacement may be $i en! "his patient3 with only low $rade endometrial

hyperplasia on patholo$ic e aluation3 has no contraindication to estro$en and would likely benefit si$nificantly from estro$en replacement therapy! Alpra2olam &choice A) is a ben2odia2epine and would not be the first line treatment for this patient#s hot flashes! .lonidine &choice B) is an antihypertensi e that has been shown3 in some studies3 to be effecti e in the treatment of hot flashes! 'owe er3 the most effecti e treatment is estro$en! "he oral contracepti e pill &choice /) would not be indicated for this patient as the le els of hormones are in excess of those needed durin$ the postmenopausal period! ?aloxifene &choice E) is a selecti e estro$en receptor modulator! *t has been appro ed for the pre ention of postmenopausal osteoporosis! 'owe er3 some patients experience an increase in hot flashes while takin$ raloxifene! "hus3 estro$en would be preferable to raloxifene for this patient whose primary complaint is hot flashes! -------------------------------------------------------------------------------=7) A 77-year-old primi$ra id woman at 8 weeks# $estation comes to the physician for her first prenatal isit! )he has had some nausea but no other complaints! )he has had no bleedin$ per a$ina or abdominal pain! )he had an o arian cystectomy at a$e 18 but no other medical or sur$ical problems! )he takes no medications and has no known dru$ aller$ies! Examination is unremarkable except for an 8-week-si2ed non-tender uterus! "he patient wants information on itamin supplementation durin$ pre$nancy! ,hich of the followin$ represents the correct amount of itamin A supplementation this patient should take dailyA! 1;3;;; *0 B! 7:3;;; *0 .! :;3;;; *0 /! 1;;3;;; *0 E! @itamin A supplementation durin$ pre$nancy is not recommended Explanation1 "he correct answer is E! @itamin A is an important itamin for human reproduction and normal bodily functionin$3 and itamin A deficiency is a problem throu$hout much of the world! *n the 0!)! and other de eloped nations3 howe er3 the o erwhelmin$ ma4ority of women ha e sufficient stores of itamin A in the li er! "hus3 itamin A supplementation durin$ pre$nancy is not needed or recommended for most women! *n fact3 itamin A supplementation has been associated with birth defects3 includin$ cranial neural crest malformations! 9ost commonly used prenatal itamins contain :;;; *0 or less3 and this is considered acceptable! ,omen should be instructed not to take any further supplementation than this! "he only exception to this rule is for women who may be itamin A deficient because of strict e$etarianism or because they are recent emi$rants from countries in which itamin A deficiency is endemic! ?ecent studies ha e su$$ested that itamin A supplementation with as little as 1;3;;; *0 &choice A) per day may cause birth defects! "herefore3 this amount of supplementation should be a oided! "he probable terato$enic dose of itamin A3 notwithstandin$ the abo ementioned study3 is 7:3;;; *0 &choice B) to :;3;;; *0 &choice .)! Patients should therefore be instructed to a oid these le els! 1;;3;;; *0 &choice /) would certainly not be recommended!

-------------------------------------------------------------------------------=3) A 7A-year-old woman comes to the emer$ency department because of abdominal distension and shortness of breath! Approximately 1 week a$o3 she underwent fertility treatment with o ulation induction and oocyte retrie al! )he has a history of polycystic o arian syndrome but no other medical problems! )he had laparoscopy 1 year a$o as part of a fertility e aluation! )he has no known dru$ aller$ies! 'er temperature is 38 . &A8!> D)3 blood pressure is 8;E=; mm '$3 pulse is 13;Emin3 and respirations are 78Emin! Physical examination is remarkable for crackles at the lun$ bases bilaterally and a distended3 nontender abdomen with a fluid wa e! 0ltrasound demonstrates bilaterally enlar$ed o aries &each G1; cm) and free fluid in the abdomen! 0rine h.( is ne$ati e! ,hich of the followin$ is the most likely dia$nosisA! Ectopic pre$nancy B! 'emorrha$ic o arian cyst .! B arian hyperstimulation syndrome /! B arian torsion E! "ubo-o arian abscess Explanation1 "he correct answer is .! "his patient has a presentation that is most consistent with o arian hyperstimulation syndrome &B')))! B')) most often occurs in patients under$oin$ o ulation induction with $onadotropins3 althou$h it can also occur with use of clomiphene citrate! "he si$ns and symptoms of B')) run a spectrum dependin$ on whether the disease is mild3 moderate3 or se ere! *n mild B'))3 the o aries are less than : cm3 and the patient has mild wei$ht $ain and pel ic discomfort! *n moderate B'))3 the o aries can be up to 1; cm in diameter3 and the patient has at least a 1;-pound wei$ht $ain3 nausea3 and omitin$! *n se ere B'))3 the o aries are $reater than 1; cm3 with ascites3 hydrothorax3 hemoconcentration3 and oli$uria! 9ana$ement depends on the se erity of the syndrome3 with mild cases bein$ mana$ed conser ati ely and more se ere cases bein$ mana$ed more a$$ressi ely with the possible need for paracentesis3 thoracentesis3 or sur$ery! Pel ic or abdominal examinations should not be performed if B')) is on the differential dia$nosis because examination can lead to rupture of the o arian capsule! E aluation should be done with a careful ultrasound examination! Ectopic pre$nancy &choice A) can cause abdominal distension! 'owe er3 this patient has a ne$ati e h.(3 which effecti ely rules out pre$nancy! A hemorrha$ic o arian cyst &choice B) can also cause abdominal distension! 'owe er3 with a hemorrha$ic cyst3 pain is most often the presentin$ complaint! "he distension is usually caused by intraperitoneal bleedin$3 which causes si$nificant pain and tenderness on examination! "his patient has no tenderness on examination! B arian torsion &choice /) causes si$nificant pain! Abdominal pain and tenderness are not the predominant features of this patient#s presentation! "ubo-o arian abscess &choice E) causes si$nificant pain and often a fe er! "his patient is afebrile3 with no abdominal tenderness! --------------------------------------------------------------------------------

==) A 7=-year-old woman3 $ra ida 33 para 73 comes to the physician for her first prenatal isit! 'er last menstrual period was 8 weeks a$o3 and a home pre$nancy test was positi e! )he states that this pre$nancy3 like her last two pre$nancies3 was unintended! )he had been usin$ condoms for birth control in all three instances! )he had normal a$inal deli eries 7 and = years a$o! ,hich of the followin$ is the most likely reason for condom failureA! Aller$ic reaction B! Breaka$e .! *mproper and inconsistent use /! 9anufacturin$ defects E! @a$inal infection Explanation1 "he correct answer is .! .ondoms pro ide an excellent method both of birth control and of pre ention of sexually transmitted diseases &)"/s)! ,hen they are properly and consistently used3 they are approximately A8< effecti e! 'owe er3 actual use or typical use of the condom aries3 and3 in practice3 they are probably around 8;< effecti e! *mproper and inconsistent use accounts for almost all of the discrepancy between the effecti eness with 5perfect5 ersus 5typical5 use! Proper condom use re%uires that a new condom is used for each act of intercourse3 that some room is left at the tip3 that the penis is withdrawn while still erect3 that the condom is held on firmly to keep it from slippin$ off as the penis is withdrawn3 and that the condom is used with water-based3 not oil-based3 lubricants! Aller$ic reaction &choice A) can be a problem with latex condoms in men or women with latex aller$ies! 'owe er3 the reaction itself should not cause condom failure! Breaka$e &choice B) is rare with condoms! 9ost reports put condom breaka$e rates at less than 7< and most of these are due to incorrect use &e!$!3 not lea in$ room at the tip)! 9anufacturin$ defects &choice /) are also rare! .ondoms are re$ulated by the 0!)! Dood and /ru$ Administration3 which tests numerous batches! )amples that fail testin$ lead the entire batch to be discarded! @a$inal infection &choice E) is an unlikely cause of condom failure! -------------------------------------------------------------------------------=:) A 8:-year-old woman comes to the physician because of abdominal distension! )he states that she always feels bloated and that she $ets full %uickly when eatin$! )he has hypertension3 for which she takes an an$iotensin con ertin$ en2yme &A.E) inhibitor3 and no other medical problems! Examination shows abdominal distension and a positi e fluid wa e! Pel ic examination re eals a lar$e3 nontender ri$ht adnexal mass! Abdominal ." scan demonstrates masses on both o aries3 ascites3 and omental cakin$! .A-17: le el is si$nificantly ele ated! )erum alpha-fetoprotein &ADP) and human chorionic $onadotropin &h.() are ne$ati e! ,hich of the followin$ is the most likely dia$nosisA! .horiocarcinoma B! .ystic teratoma &dermoid) .! Embryonal carcinoma /! Epithelial o arian cancer E! )ertoli stromal cell tumor

Explanation1 "he correct answer is /! "he lifetime incidence of o arian cancer is 1!=< &1 in 8; women)! 0nfortunately3 there are no early symptoms of o arian cancer1 presentin$ symptoms ha e to do with increasin$ tumor mass! "his patient has abdominal discomfort and early satiety3 which are often associated with o arian cancer! Bther symptoms that may be seen are fati$ue3 urinary fre%uency3 and shortness of breath! "he most common findin$ on examination is a pel ic mass3 as this patient has! 9asses3 ascites3 and e idence of tumor spread may be seen on ." scan! ?ou$hly 8;< of all o arian cancers are deri ed from o arian epithelium! "he other ma4or cate$ories of o arian tumors are $erm cell tumors3 sex cord stromal tumors3 and metastatic tumors! "he fact that this patient is 8: years old3 has what appears to be o arian cancer3 and has an ele ated serum .A-17: le el &seen in approximately 8;< of women with epithelial cancers)3 makes epithelial o arian cancer most likely! Con$estational choriocarcinoma &choice A) of the o ary is extremely rare! Durthermore3 in a patient with choriocarcinoma3 the serum h.( should be ele ated! .ystic teratoma &dermoid) &choice B) accounts for 7: to =;< of all o arian neoplasms! 'owe er3 most teratomas are dia$nosed in premenopausal women and they do not usually present as bilateral masses3 ascites3 and e idence of tumor spread with an ele ated serum .A-17: le el! Embryonal carcinoma &choice .) is a rare $erm cell tumor! )erum ADP and h.( are often ele ated with this tumor! )ertoli stromal cell tumor &choice E) is a rare sex cord stromal tumor that exhibits a male or testicular direction of differentiation! -------------------------------------------------------------------------------=>) A 38-year-old woman3 $ra ida 13 para ;3 at 8 weeks# $estation comes to the physician for a prenatal isit! )he has had no bleedin$ from the a$ina or abdominal pain and no complaints! )he has a lon$ history of mi$raine headache and recently de eloped peptic ulcer disease &P0/)! Examination shows a nontender 8-week si2ed uterus but is otherwise unremarkable! "he patient is ery concerned that her mi$raine headaches and peptic ulcer disease will make her pre$nancy intolerable! ,hich of the followin$ is the most appropriate responseA! Pre$nancy is associated with impro ement of mi$raines and P0 /! B! Pre$nancy is associated with worsenin$ of mi$raines and P0 /! .! Pre$nancy is associated with worsenin$ mi$raines and impro ed P0 /! /! Pre$nancy is associated with impro ed mi$raines and worsened P0 /! E! Pre$nancy has no effect on mi$raines or P0 /! Explanation1 "he correct answer is A! ,ithin the last decade it has been reco$ni2ed that 'elicobacter pylori plays a central role in the patho$enesis of chronic $astritis and peptic ulcer disease &P0/)! Acid

secretion is also known to play a role! /urin$ pre$nancy3 $astric acid secretion is reduced and there is also a decrease in $astric motility! Pre$nancy is also associated with increased mucus secretion3 which is felt to ha e a protecti e effect on the $astrointestinal tract! Because of these physiolo$ic chan$es durin$ pre$nancy3 acti e peptic ulcer disease durin$ pre$nancy is extremely uncommon durin$ pre$nancy! ,omen rarely de elop P0/ in pre$nancy and women with P0/ note considerable impro ement! Estimates are that A;< of patients with acti e P0/ will experience remission durin$ pre$nancy! 'owe er3 once the pre$nancy is completed3 almost all women will experience recurrence in the next few years! A si$nificant portion &up to 7;<) of women experience mi$raine headaches durin$ their li es3 so issues re$ardin$ mi$raines and pre$nancy are not uncommon! As with P0/3 there is usually a dramatic impro ement of mi$raines durin$ pre$nancy! Estimates are that 8;< of women with mi$raines will ha e impro ement! 'owe er3 it is interestin$ to note that some women will ha e their first experience with mi$raine durin$ pre$nancy and may only experience mi$raine with pre$nancy! 9i$raine headache durin$ pre$nancy should be treated with acetaminophen and antiemetics! .odeine or meperidine may be $i en for se ere headaches! Er$otamine preparations should be a oided in pre$nancy! "he safety of sumatriptan durin$ pre$nancy has not been established3 so pre$nant patients3 at present3 should seek alternati e medications! "o state that pre$nancy is associated with worsenin$ of mi$raines and P0/ &choice B)3 worsenin$ mi$raines and impro ed P0/ &choice .)3 or impro ed mi$raines and worsened P0/ &choice /) is incorrect! As explained abo e3 pre$nancy is associated with both impro ed mi$raines and P0 /! "o state that pre$nancy has no effect on mi$raines or P0/ &choice E) is also incorrect! "hese two illnesses are examples of the profound effect that pre$nancy can ha e on certain conditions! -------------------------------------------------------------------------------=8) A 73-year-old primi$ra id woman at 7A-weeks# $estation comes to the physician because of contractions! )he states that they ha e been occurrin$ e ery 3-: minutes for the past few hours and that they are worsenin$ in intensity! Examination re eals that the patient is afebrile and her abdomen is nontender! 'er cer ix is 3 cm dilated3 and the fetus is in ertex position! "he patient is started on *@ ma$nesium sulfate and penicillin and $i en an intramuscular in4ection of betamethasone! ,hich of the followin$ represents the most si$nificant conse%uence of this patient#s preterm laborA! .esarean deli ery B! Dorceps assisted a$inal deli ery .! 9aternal infection /! Ceonatal prematurity E! )houlder dystocia Explanation1 "he correct answer is /! Preterm labor is a ma4or problem in the 0!)! Estimates are that it affects somewhere between :< and 1;< of all pre$nancies! "he exact etiolo$y of the preterm labor is usually difficult to determine! "heories abound as to why some women de elop contractions and cer ical dilation prior to term whereas others do not! Possible etiolo$ies

include infection3 dehydration3 cer ical weakness3 multiple $estation3 and uterine anomalies! "he most si$nificant conse%uence of preterm labor is that it often results in premature deli ery of a premature neonate! Premature neonates are at hi$h risk for pulmonary immaturity3 intra entricular hemorrha$e3 necroti2in$ enterocolitis3 apnea3 bradycardia3 and other complications! .esarean deli ery &choice A) is not necessarily a conse%uence of preterm labor! "his fetus is in the ertex position3 and this patient3 should she ha e unstoppable preterm labor3 could ha e a a$inal deli ery! Dorceps assisted a$inal deli ery &choice B) is not necessarily a conse%uence of preterm labor! *f this patient is in unstoppable preterm labor3 she may ha e a a$inal deli ery without the need of forceps! 9aternal infection &choice .) may be the cause of this patient#s preterm labor3 but it is unlikely to be the most si$nificant conse%uence of the preterm labor! )houlder dystocia &choice E) has been reported to occur e en in a preterm deli ery3 althou$h this is rare! "he most si$nificant conse%uence of preterm labor is neonatal prematurity3 not shoulder dystocia! -------------------------------------------------------------------------------=8) A 77-year-old woman comes to the physician for an annual examination! )he has normal periods e ery month and has no complaints! )he has no medical problems but does smoke one pack of ci$arettes per day! )he has intercourse with more than one partner! Examination is unremarkable3 includin$ a normal pel ic examination! A Papanicolaou smear shows a hi$h-$rade s%uamous intraepithelial lesion! ,hich of the followin$ is the most appropriate next step in mana$ementA! ?epeat Pap smear in 1 year B! ?epeat Pap smear in > months .! Perform colposcopy /! Perform a cone biopsy E! Perform a hysterectomy Explanation1 "he correct answer is .! "he Papanicolaou smear is an excellent screenin$ techni%ue for cer ical cancer because it is easy to perform3 has a relati ely low-cost3 and is nonin asi e! All women who are either sexually acti e or older than 18 should ha e annual Pap smears! "he downside of the Pap smear is that it has a low sensiti ity and hi$h false-ne$ati e rate! "hat is3 many women with abnormal cer ical cells will ha e a ne$ati e Pap smear! 'owe er3 if a woman recei es an annual Pap smear3 it is likely that the lesion will be disco ered! Because the pro$ression of cer ical dysplasia to cancer takes time3 it is belie ed that these lesions will be disco ered early enou$h to cure them so lon$ as annual screenin$ occurs! "his patient has what is called a hi$h-$rade s%uamous intraepithelial lesion &'()*+)! "hese lesions ha e a si$nificant risk of e entually pro$ressin$ to in asi e cer ical cancer if they are not treated! "herefore3 any patient with '()*+ on a Pap smear must under$o colposcopy with directed biopsies so that the lesion can be remo ed! "o repeat the Pap smear in 1 year &choice A) is incorrect! A 1-year follow-up is appropriate for a patient with normal Pap smears! "his patient has '()*+ and therefore needs much closer follow-up! "o repeat the Pap smear in > months &choice B) is incorrect! A >-month follow-up is appropriate for patients with a Pap smear showin$

atypical s%uamous cells of undetermined si$nificance &A).0))3 or in some patients with a low-$rade s%uamous intraepithelial lesion &+()*+)! "o perform a cone biopsy &choice /) would be incorrect! Prior to sur$ical mana$ement of an abnormal Pap smear result3 a tissue dia$nosis should be made &Pap smear pro ides only a cytolo$ic dia$nosis)! "his re%uires colposcopy with directed biopsies! "o perform a hysterectomy &choice E) would not be proper mana$ement! 'ysterectomy as treatment for '()*+ is $enerally not indicated! )ome patients with recurrent '()*+3 or those with lesions that cannot be properly treated with local therapy3 may be candidates for hysterectomy! 'owe er3 this patient is 77 years old and likely desires future fertility! Also3 this is her first '()*+ Pap smear! "herefore3 the proper mana$ement is to perform a colposcopy! -------------------------------------------------------------------------------=A) A =-year-old $irl is brou$ht to the physician by her mother because of a bloody3 $reenish3 malodorous a$inal dischar$e! "he dischar$e was first noted 3 days a$o and has worsened since then! "he $irl has no other symptoms! "he mother reports no concerns re$ardin$ abuse of the child! Examination is attempted but impossible because of the child#s absolute refusal to be examined! )e eral efforts at persuasion are made but are unsuccessful! ,hich of the followin$ is the most appropriate next step in mana$ementA! ?eassurance and expectant mana$ement B! Antibiotic administration .! Police notification /! Examination under anesthesia E! Pel ic examination with physical restraint Explanation1 "he correct answer is /! A dischar$e such as that described abo e re%uires a full e aluation! "he differential dia$nosis includes infection3 tumor3 trauma3 and a$inal forei$n body! *n a =-year-old $irl3 a a$inal forei$n body is a common cause of a $reenish3 bloody3 foul-smellin$ a$inal dischar$e! "he most common forei$n body found is toilet paper or stool! *t can often be difficult to perform any type of examination on a youn$ child! @a$inal forei$n bodies are typically seen in $irls between 3 and 8 years of a$e3 and3 at these a$es3 many will refuse examination! 'owe er3 it is absolutely essential to determine the etiolo$y of the dischar$e! Dailure to remo e a a$inal forei$n body can lead to dama$e to the a$ina3 se ere pel ic inflammatory disease3 or peritonitis! "hus3 this child needs to ha e an examination! Because she refuses to be oluntarily examined3 the examination should be performed under anesthesia3 at which time a$inoscopy can be performed! ?eassurance and expectant mana$ement &choice A) would not be appropriate for this child! "here is nothin$ reassurin$ about ha in$ a bloody3 malodorous a$inal dischar$e! "his dischar$e could3 for example3 represent a mali$nancy or lead to se ere infection! "herefore3 expectant mana$ement would not be appropriate! Antibiotic administration &choice B) would not be the correct next step! *t is unclear what is causin$ the dischar$e and to simply assume that the etiolo$y is infectious3 and to send the patient home with antibiotics would not be correct! Police notification &choice .) would not be the most appropriate next step! =-year-old children can de elop a$inal forei$n bodies without abuse takin$ place! A thorou$h e aluation should be conducted3 includin$ cultures for

sexually transmitted diseases3 but police notification would not be the next step! Pel ic examination with physical restraint &choice E) should not be performed on a child! /oin$ so risks psycholo$ical distress and possible future sexual dysfunction! -------------------------------------------------------------------------------:;) A 38-year-old woman3 $ra ida 33 para 73 at 37 weeks# $estation comes to the physician because of bleedin$ from the a$ina! )he states that this mornin$ she passed 7 %uarter-si2ed clots of blood from her a$ina! Btherwise3 she states that she is feelin$ well! "he baby has been mo in$ normally and she has had no contractions or $ush of fluid from the a$ina! 'er obstetrical history is si$nificant for 7 low-trans erse cesarean deli eries for non-reassurin$ fetal heart rate tracin$s! An ultrasound is performed that demonstrates a complete placenta pre ia! Dor which of the followin$ conditions is this patient at hi$hest riskA! /ystocia B! *ntrauterine fetal demise &*0D/) .! Placenta accreta /! Preeclampsia E! 0terine rupture Explanation1 "he correct answer is .! Placenta pre ia is defined as a placenta located o er the cer ical os! "here are 3 ma4or types! .omplete pre ia describes a placenta that completely co ers the cer ical os! Partial pre ia is a placenta that co ers some of the cer ical os3 with the remainder of the os unco ered by the placenta! 9ar$inal pre ia describes a placenta that is located at the ed$e of the cer ical os! "hree ma4or risk factors for placenta pre ia are maternal a$e3 minority race3 and pre ious cesarean deli ery! Placenta accreta describes the condition in which there is abnormal attachment of the placenta to the uterine wall! *n this condition3 the decidua basalis is absent and the placenta is attached to the myometrium &accreta) or in ades into the myometrium &increta)3 or perforates throu$h the myometrium &percreta)! Patients with a placenta pre ia and no prior cesarean deli eries ha e a :< risk of ha in$ a placenta accreta! Patients with a pre ia and one prior cesarean deli ery ha e a 7:< risk of ha in$ an accreta! And patients with a placenta pre ia and 7 or more prior cesarean deli eries ha e a $reater than :;< risk of ha in$ a placenta accreta! 9any patients with a pre ia and accreta will re%uire a hysterectomy at the time of deli ery! "his patient3 with a history of 7 prior cesarean deli eries and a placenta pre ia is at hi$hest risk for placenta accreta! "his patient would not be considered to be at hi$hest risk of dystocia &choice A) because3 with a placenta pre ia3 she would not be allowed to labor and3 therefore3 would not be at risk of dystocia! "here appears to be no stron$ association between placenta pre ia and intrauterine fetal demise &choice B) or preeclampsia &choice /)! 0terine rupture &choice E) is a concern in women who ha e had prior cesarean deli eries3 and the risk of rupture does rise with the number of pre ious cesarean deli eries! *t is of particular concern if the woman is in labor! "his patient3 with a placenta pre ia3 howe er3 will not be allowed to labor!