A 29-year-old woman comes to the physician for follow-up of a right breast lump. The patient first noticed the lump 4 months ago. It was aspirated at that time, and cytology was negative, but the cyst recurred about 1 month later. The cyst was re-aspirated 2 months ago and, again, the cytology was negative. The lump has recurred. Examination reveals a mass at 10 o'clock, approximately 4 cm from the areola. Ultrasound demonstrates a cystic lesion. Which of the following is the most appropriate next step in management? A. Mammography in 1 year B. Ultrasound in 1 year C. Tamoxifen therapy D. Open biopsy E. Mastectomy Explanation: The correct answer is D. Breast lumps are a common complaint in women. Many of these masses are benign processes. Benign conditions of the breast include fibrocystic disease, fibroadenomas, galactoceles, abscesses, and necrosis. It is appropriate to aspirate a palpable macrocyst in the breast; the fluid should be placed on a slide and sent for cytologic evaluation. If the cytology is negative, no further treatment is needed. Some would argue that if the cyst recurs, it may be aspirated again. However, when a lesion recurs twice, as has occurred in this patient, open biopsy is warranted. To wait to perform mammography in 1 year (choice A) or ultrasound in 1 year (choice B) would be incorrect management. First, if a malignancy is present, waiting another year will allow progression of the cancer. Second, the mammogram is not definitive. Imaging can contribute information to the workup of a breast mass, but the definitive diagnosis rests on histologic evaluation. Tamoxifen therapy (choice C) is used to both prevent and treat breast cancer. However, this patient does not yet have a diagnosis. She has a cystic mass that has been aspirated twice and has recurred twice. She therefore requires a biopsy to establish a diagnosis prior to the institution of any treatment. Mastectomy (choice E) would not be indicated for this patient. Again, this patient does not have a diagnosis, and to perform a mastectomy for a recurrent cyst would be inappropriate. An 18-year-old woman comes to the physician for advice regarding birth control. She has been sexually active since the age of 15 and has had numerous sexual partners since that time. She has tried the oral contraceptive pill twice, for approximately two cycles each time, but stopped because of irregular bleeding. She has had gonorrhea once and Chlamydia twice. She does not smoke. Physical examination is unremarkable. Which of the following forms of birth control should be recommended for this patient? A. Condoms B. Diaphragm C. Intrauterine device D. Oral contraceptive pill E. Tubal ligation Explanation: The correct answer is A. All of the above options will provide birth control for this patient. However, another major factor for this patient is the prevention of sexually transmitted disease. Other than abstinence, condoms provide the best protection against the acquisition of sexually transmitted diseases. This patient, with her early onset of intercourse at the age of 15 and her numerous sexual partners, is at high risk for HIV, hepatitis, herpes, chlamydia, gonorrhea, syphilis, human papillomavirus, and the eventual development of cervical cancer. It is absolutely essential that she be counseled regarding condom use and the importance of her protecting herself from sexually transmitted diseases as well as pregnancy. The diaphragm (choice B) is an effective method of birth control for motivated women who are able to use this method with each episode of intercourse. Because it covers the cervix, it provides some protection against disease. However, it does not provide as much protection against sexually transmitted diseases as condoms do. The intrauterine device (choice C) is absolutely contraindicated in a woman with numerous sexual partners and a recent history of sexually transmitted disease. Furthermore, it is highly suboptimal for young women, in whom a pelvic infection could lead to reduced or absent future fertility. The oral contraceptive pill (OCP) (choice D) would provide this patient with protection against pregnancy; however, it would not protect her from sexually transmitted diseases. An ideal approach may be to have her use both the OCP and condoms. However, consistent use of both can be difficult. Tubal ligation (choice E) would provide this patient with no protection against sexually transmitted disease. Furthermore, except in very rare circumstances, it is contraindicated for an 18-year-old. A 53-year-old woman comes to the physician for an annual examination. She has no complaints. She has hypertension, for which she takes a thiazide diuretic, but no other medical problems. Her past gynecologic history is significant for normal annual Pap tests for many years, her last being 2 months ago. A recent mammogram was negative. Heart, lung, breast, abdomen, and pelvic examination are unremarkable. Which of the following procedures or tests should most likely be performed on this patient? A. Chest x-ray B. Pap test C. Pelvic ultrasound D. Prostate-specific antigen (PSA) E. Rectal examination Explanation: The correct answer is E. Cancer screening should be an essential part of an annual examination. Colorectal cancer is a major cause of serious morbidity and mortality for women in the U.S.: greater than 50,000 new cases are diagnosed each year, and there are more than 25,000 deaths from colorectal cancer. Screening should begin at age 50 in asymptomatic women with no significant family history. Screening consists of a digital rectal examination with fecal occult blood testing. This can be performed at the same time that pelvic examination is performed. Sigmoidoscopy should be performed every 3-5 years. This patient has no indication for a chest x-ray (choice A). Lung cancer has surpassed breast cancer as the major cause of cancer death in women. However, chest x-ray films are not used for lung cancer screening. There is currently no technique available for routine screening for lung cancer. The Pap test (choice B) is an important method of screening for cervical cancer and should be performed annually. However, this patient had a normal Pap test 2 months ago. Pelvic ultrasound (choice C) is not indicated in this patient. She has nothing abnormal in her history or physical that would warrant pelvic ultrasound. Pelvic ultrasound is not used for cancer screening. Prostate-specific antigen (PSA) (choice D) is an appropriate test in men. PSA testing would not be indicated in this (female) patient. A 75-year-old woman comes to the physician because of irregular vaginal bleeding. She has been menopausal for the past 25 years, but has noted on-and-off spotting for the past 2 years, which she finds intolerable. She has a complicated past medical history including hypertension, diabetes, and severe chronic obstructive pulmonary disease. Examination is unremarkable. An endometrial biopsy is performed that demonstrates an endometrial polyp with atypical cells that are difficult to grade. Which of the following is the most appropriate next step in management? A. Hormone replacement therapy B. Oral contraceptive pill C. Hysteroscopy D. Laparoscopy E. Hysterectomy Explanation: The correct answer is C. This patient is likely having irregular spotting secondary to the polyp. Endometrial polyps are projections of endometrial tissue that protrude into the endometrial cavity. They can be seen in women of any age, but are most commonly seen in perimenopausal women. This problem should be addressed for 2 reasons: 1. The bleeding per vagina is distressing to the patient. 2. There are some atypical cells from the biopsy that may represent cancer and polyps can contain malignant cells within them. Therefore, the polyp should be removed. The question then becomes how best to remove it. A hysteroscopy can be performed under monitored anesthesia care (MAC), an approach that provides adequate anesthesia without requiring the patient to have general anesthesia. It would be preferable to avoid general anesthesia in a patient with so many medical conditions. Hysteroscopy would allow visualization of the entire uterine cavity and removal of the polyp. A curettage should be performed afterward to fully sample the cavity. Hormone replacement therapy (choice A) would not be the most appropriate next step. First, the polyp must be removed and histologic evaluation of the polyp and endometrial tissues performed to rule out malignancy prior to instituting hormone replacement therapy. The oral contraceptive pill (choice B) would not be appropriate management for a 75-year-old woman, as the dose of hormones is higher than necessary. Laparoscopy (choice D) would not be indicated. This patient is having spotting, which is an intrauterine process. Laparoscopy allows visualization of only the external, serosal uterine surface. Hysterectomy (choice E) would not be the most appropriate management. Hysterectomy would take care of the patient's spotting and would provide tissue for pathologic diagnosis. However, in this patient with multiple medical problems, the same goals can be achieved with the less invasive procedure of hysteroscopy. A 21-year-old woman comes to the physician because of "bumps" on her vulva that she has just recently noticed. These bumps do not cause her symptoms, but she wants to know what they are and wants them removed. She has no medical problems, takes no medications, and has no allergies to medications. She smokes one-half pack of cigarettes per day. She is sexually active with 3 partners. Examination shows 3 cauliflower-like lesions on the right labia majora. Which of the following is the most appropriate next step in management? A. Acyclovir B. Penicillin C. Cone biopsy D. Cryotherapy E. Vulvectomy Explanation: The correct answer is D. This patient has findings that are most consistent with condyloma acuminata, or genital warts. Condyloma acuminata is caused by the human papillomavirus. This virus, of which there are many different subtypes, infects epidermal cells and can cause warty growths. When the virus affects skin cells on the hands, the result is the common warts that are often seen in children. When the virus affects cells on the perineum, the result is condyloma acuminata. Diagnosis is made on the basis of the classic, verrucous (cauliflower-like) appearance of the lesions. Treatment is with local destruction. This local destruction can be achieved in a variety of ways including with cryotherapy (i.e. freezing of the skin), laser therapy, trichloroacetic acid (i.e. chemical destruction of the skin), or imiquimod. However, while the lesions themselves are often successfully treated with these locally destructive agents, the virus is not usually completely eradicated and recurrences of the lesions may occur. Acyclovir (choice A) is used to treat herpes viruses. Condyloma acuminata is caused by the human papillomavirus and, therefore, acyclovir is not used. Penicillin (choice B) is an antibiotic effective against bacteria, and not the human papillomavirus. Cone biopsy (choice C) is performed on the cervix when a patient has high-grade dysplasia or cancer. While there is an association between human papillomavirus infection and cervical dysplasia, cone biopsy would not be indicated for a patient on the basis of the presence of condyloma. Vulvectomy (choice E) is performed on patients for vulvar dysplasia or cancer. It is not indicated for patients with condyloma. A 29-year-old primigravid woman at 34 weeks' gestation comes to the physician for a prenatal visit. At 28 weeks, she failed her 50-g, 1-hour oral glucose-loading test. She also failed her follow-up 100-g, 3-hour oral glucose tolerance test, with a normal fasting glucose, but abnormal 1, 2, and 3-hour values. Over the past several weeks, she has maintained good control of her fasting and 2-hour postprandial glucose levels by adhering to the diet recommendations of her physician. She asks the physician what effect her type of diabetes can have on her or her fetus. Which of the following is the most appropriate response? A. Gestational diabetes is associated with fetal anomalies B. Gestational diabetes is associated with intrauterine growth restriction C. Gestational diabetes is associated with macrosomia D. Gestational diabetes is not associated with future diabetes E. Gestational diabetes with normal fasting glucose is associated with stillbirth Explanation: The correct answer is C. Gestational diabetes is defined as glucose intolerance that either has its onset or its first recognition during pregnancy. Gestational diabetes is usually diagnosed by means of oral glucose tolerance testing. Patients with gestational diabetes and normal fasting glucose levels have two major risks. The first is fetal macrosomia. Women with gestational diabetes are known to have larger babies, and this creates an increased risk of complications of delivery including shoulder dystocia and cesarean delivery. The second risk is of the eventual development of overt diabetes. Fifty percent of women with gestational diabetes will go on to develop overt diabetes within the next 20 years. Patients with gestational diabetes and abnormal fasting glucose levels do have an increased risk of stillbirth. To state that gestational diabetes is associated with fetal anomalies (choice A) is incorrect. However, patients with overt diabetes do have an increased risk of fetal anomalies. To state that gestational diabetes is associated with intrauterine growth restriction (choice B) is not correct. Gestational diabetes is associated with macrosomia. To state that gestational diabetes is not associated with future diabetes is incorrect (choice D), as explained above. To state that gestational diabetes with normal fasting glucose is associated with stillbirth (choice E) is incorrect. However, overt diabetes and gestational diabetes with abnormal fasting glucose levels (class A2) are associated with stillbirth. A 34-year-old woman, gravida 3, para 2 at term comes to the labor and delivery ward with a gush of blood, abdominal pain, and irregular, painful contractions. Her prenatal course was significant for her being Rh negative and antibody negative. Her temperature is 37 C (98.6 F), pulse is 110/minute, blood pressure is 110/70 mm Hg, and respirations are 12/minute. Abdominal examination shows a tender abdomen and cervical examination shows the cervix to be closed and long with a significant amount of blood in the vagina. The fetal heart rate is in the 170s with moderate to severe variable decelerations with contractions. The diagnosis of placental abruption is made and an emergent cesarean delivery is performed. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send? A. Apt test B. Complete blood count C. Kleihauer-Betke D. Partial thromboplastin time E. Serum potassium Explanation: The correct answer is C. Women that are Rh negative are at risk for developing Rh isoimmunization. Rh isoimmunization occurs when an Rh-negative mother becomes exposed to the Rh antigen on the red blood cells of an Rh-positive fetus. This exposure may lead the mother's immune system to become sensitized to the Rh antigen such that in a future pregnancy with an Rh-positive fetus, the mother's immune system may "attack" the Rh antigen on the fetal red blood cells. This immune response may lead to the development of fetal anemia, hydrops, and death. To prevent Rh isoimmunization from occurring, Rh-negative women who are not Rh alloimmunized should receive RhoGAM (anti-D immune globulin) at 28 weeks of gestation, within 72 hours after the birth of an Rh-positive infant, after a spontaneous abortion, or after invasive procedures such as amniocentesis. RhoGAM should also be strongly considered in cases of threatened abortion, antenatal bleeding, external cephalic version, or abdominal trauma. The amount that is usually given after the delivery of an Rh-positive fetus is 300 µg. This amount is sufficient to cover a fetal to maternal hemorrhage of 30 mL (or 15 mL of fetal cells). However, some women will have a fetal to maternal hemorrhage that is in excess of this 30 mL—especially in cases such as manual removal of the placenta or placental abruption (as this patient had). To determine the amount of fetal to maternal hemorrhage that occurred, it is necessary to perform a Kleihauer-Betke test which is an acid-dilution procedure that allows fetal red blood cells to be identified and counted. Knowing the amount of fetal to maternal hemorrhage that took place allows the correct amount of RhoGAM to be given. An apt test (choice A) is used to differentiate fetal from maternal blood. It can be used in the diagnosis of vasa previa or with neonatal melena. A complete blood count (choice B) will demonstrate the amount of maternal hemorrhage, but not the amount of fetal to maternal hemorrhage. Partial thromboplastin time (choice D), and serum potassium (choice E) do not allow for the determination of the amount of fetal to maternal hemorrhage. A 28-year-old primigravid woman at 8 weeks' gestation comes to the physician for her first prenatal visit. A home pregnancy test was positive. She has no complaints. She is concerned, however, because she is a carrier of the fragile X mutation. Her husband is also known to be a carrier. This is a highly desired pregnancy. She wants to know whether there is a way to determine whether the fetus is affected. Which of the following is the most appropriate next step in management? A. There is nothing to offer this couple B. Offer testing of the parents C. Offer MRI of the fetus D. Offer 2nd trimester amniocentesis E. Offer termination of the pregnancy Explanation: The correct answer is D. Fragile X syndrome is the most common inherited form of mental retardation. Down syndrome may cause more absolute cases of mental retardation, but it results from a spontaneously occurring trisomy and most cases are not considered inherited. The gene for fragile X syndrome is located on the long arm of the X-chromosome. It has a complex inheritance pattern that is related to the number of repeating cytosine-guanine-guanine triplets. When greater than 200 repeats are present, a person will have the full mutation and have phenotypic fragile X syndrome. A patient with 50-200 repeats is phenotypically normal and is said to have a premutation. Along with mental retardation, related features of the fragile X syndrome include autistic behaviors, speech and language problems, facial anomalies, and macroorchidism in adult males. DNA-based molecular analysis can be used to diagnose fragile X syndrome. This can be performed on cultured amniocytes obtained at amniocentesis. Chorionic villus sampling is not considered to be reliable for the diagnosis of fragile X syndrome because of different methylation patterns in the trophoblast compared with the fetus. To state that there is nothing to offer this couple (choice A) is incorrect. As detailed above, amniocentesis can be used to allow for prenatal diagnosis of fragile X syndrome. To offer testing of the parents (choice B) would not be correct. Based on the history provided, the parents have already been tested and are known to be carriers. Their concern at this point is whether the fetus will have fragile X syndrome, and that can only be determined by genetic analysis of the fetus. To offer MRI of the fetus (choice C) would be incorrect. The diagnosis is made based on DNA-based molecular analysis and not an imaging study. To offer termination of the pregnancy (choice E) would be incorrect. This is a desired pregnancy. This patient is seeking prenatal diagnosis at this point, not termination. A 23-year-old female comes to the physician because of a swelling in her vagina. She states that the swelling started about 3 days ago and has been growing larger since. The swelling is not painful, but it is uncomfortable when she jogs. She has asthma for which she uses an albuterol inhaler, but no other medical problems. Examination shows a cystic mass 4 cm in diameter near the hymen by the patient's left labia minora. The mass is nontender and there is no associated erythema. The mass is freely mobile. The rest of the pelvic examination is unremarkable. Which of the following is the most likely diagnosis? A. Bartholin's cyst B. Condyloma lata C. Granuloma inguinale D. Hematocolpos E. Vulvar cancer Explanation: The correct answer is A. This patient has a presentation and findings that are most consistent with a Bartholin's cyst. Bartholin's cysts develop when a Bartholin's gland becomes obstructed. The Bartholin's glands are bilateral structures that are present near the posterior fourchette of the vagina at the 5 and 7 o'clock positions. They secrete mucus, particularly during sexual stimulation, which drains into the posterior vagina.They undergo rapid growth during the process of puberty and they shrink after the menopause. When the duct of the Bartholin's gland becomes obstructed, a Bartholin's cyst results. If the cyst becomes infected, the result is a Bartholin's abscess. These abscesses are usually polymicrobial in nature, although the gonococcus is implicated in about 25% of cases. Treatment of a symptomatic Bartholin's cyst is with placement of a Word catheter. This is a small balloon-tipped catheter device that is placed into a small hole that is punched into the cyst itself. This catheter allows drainage of the cyst and the formation of an epithelialized tract that will allow continued drainage once the catheter is removed. This tract should prevent the cyst from reforming. If Bartholin's cysts continue to form in spite of the use of the Word catheter, a marsupialization procedure may be tried. In this procedure, the cyst walls are sutured open to the surrounding skin to prevent re-closure and re-formation of the cyst. Condyloma lata (choice B) is a manifestation of secondary syphilis. They appear as coalesced, large, pale, flat-topped papules and not as a cystic mass. Granuloma inguinale (choice C) is also known as Donovanosis and is a sexually transmitted disease associated with the gram-negative bacillus Calymmatobacterium granulomatis. The disease is characterized by papules progressing to ulcers and not by a vulvar cyst. Hematocolpos (choice D) describes the condition in which there is blood filling the vagina. This is often seen with an imperforate hymen. Vulvar cancer (choice E) does not usually present as a single cystic mass at the introitus and, in young women, is far less common than Bartholin's cysts A 47-year-old woman comes to the physician for an annual examination. One year ago, she was diagnosed with endometrial carcinoma and underwent a total abdominal hysterectomy and bilateral salpingo- oophorectomy. She was found to have grade I, stage I, disease at that time. Over the past year, she has developed severe hot flashes that occur throughout the day and night and are worsening. She is also concerned because her mother and several of her aunts have severe osteoporosis. She wonders whether she can take estrogen replacement therapy. Which of the following is the most appropriate response? A. Estrogen replacement therapy is absolutely contraindicated B. Estrogen replacement therapy may be used, and there are no risks C. Estrogen replacement therapy may be used, but there are risks D. Estrogen replacement therapy will lead to breast cancer E. Estrogen replacement therapy will lead to cancer recurrence Explanation: The correct answer is C. The issue of whether a patient who had endometrial carcinoma can be placed on estrogen replacement therapy (ERT) is somewhat controversial. If the patient is completely free of tumor, estrogen replacement therapy should not result in recurrence. And, in this patient's case, it would be helpful for her hot flashes and osteoporosis. However, if an estrogen-dependent neoplasm is still present somewhere in her body, ERT may result in an earlier recurrence. Stage I, grade I, endometrial cancer is the lowest grade and lowest stage endometrial cancer. The risk of persistent disease is less than 5%. Many gynecologic oncologists would feel comfortable giving ERT to this patient. However, the patient must be fully informed regarding the benefits and risks of ERT. These risks include not only earlier recurrence, but also the standard risks such as venous thrombosis. To state that estrogen replacement therapy is absolutely contraindicated (choice A) is incorrect. As explained above, ERT may be given to certain patients with a history of grade I, stage I, endometrial carcinoma. To state that estrogen replacement therapy may be used and there are no risks (choice B) is not appropriate. Even in women with no history of endometrial carcinoma, there are risks to ERT. The history of endometrial carcinoma adds a further risk for this patient. To state that estrogen replacement therapy will lead to breast cancer (choice D) is incorrect. There are a number of studies that show that ERT leads to increased rates of breast cancer. There are also a number of studies that show no increased risk. Therefore, to make the definitive statement that ERT will lead to breast cancer is incorrect. As explained above, to state that ERT will lead to cancer recurrence (choice E) is not correct. A 52-year-old woman comes to the physician because of hot flashes. Her last menstrual period was 1 year ago. Over the past year, she has noted a persistence of her hot flashes, which come several times each day and are associated with a feeling of heat and flushing. They also awaken her at night and interfere with her sleep. She has no medical problems, takes no medications, and has no known drug allergies. She has a family history of cardiovascular disease and she does not smoke. Physical examination is unremarkable. She is started on estrogen and medroxyprogesterone acetate (Provera). The addition of a progestin is most likely to decrease her risk of which of the following? A. Breast cancer B. Breast pain C. Endometrial cancer D. Mood changes E. Weight gain Explanation: The correct answer is C. Unopposed estrogen is known to cause endometrial hyperplasia and cancer. Estrogen has direct effects on the growth and development of the endometrium. Studies have shown that the addition of a progestin can protect a woman from the development of endometrial hyperplasia and that the addition of a progestin to women with endometrial hyperplasia can lead the endometrium to revert to normal. Thus, any woman with a uterus who is on estrogen therapy should also be on a progestin to protect her endometrium. This is usually done by placing the patient on daily estrogen and progesterone or on cyclic progesterone. Progestins do not protect against the development of breast cancer (choice A). In fact, there is evidence that progestins may stimulate the growth of breast tumors. Breast pain (choice B) is often a result of progestin therapy. Mood changes (choice D) and weight gain (choice E) are well-known side effects of progestins. A 27-year-old woman, gravida 2, para 2, comes to the physician to have her staples removed after an elective repeat cesarean delivery. Her pregnancy course was uncomplicated. She states that she is doing well except that since the delivery she has noticed some episodes of sadness and tearfulness. She is eating and sleeping normally and has no strange thoughts or thoughts of hurting herself or others. Physical examination is within normal limits for a patient who is status post cesarean delivery. Which of the following is the most likely diagnosis? A. Maternity blues B. Postpartum depression C. Postpartum mania D. Postpartum psychosis E. Poststerilization depression Explanation: The correct answer is A. Maternity blues is the term used to describe a common postpartum reaction that occurs in 50 to 70% of postpartum patients. It is characterized by tearfulness, restlessness, and anxiety. Symptoms typically start in the first few days postpartum and resolve within 2 weeks. However, certain patients continue to have the symptoms for several weeks. Many symptoms may be seen in association with this disorder including headache, backache, fatigue, forgetfulness, insomnia, weeping, depression, anxiety, and negative feelings toward the newborn infant. Interestingly, another component of the syndrome may be episodes of elation, and such mood lability can be especially distressing for the new mother. It is unclear what the etiology of these symptoms is. Certainly, the postpartum period with a newborn can be stressful and life changing, which can certainly lead to mood changes and a number of emotional responses. Some researchers have argued that changes in hormone levels are at the root of the maternity blues, but this has never been definitively proven. This patient does not have evidence of a true postpartum depression (e.g., insomnia, lack of appetite, or anhedonia) or postpartum psychosis (e.g., bizarre thoughts) and she does not have any thoughts of hurting herself or her baby. Therefore, the most likely diagnosis is maternity blues and she should be given support and reassurance. The patient must also be cautioned, however, that if her symptoms do not resolve, or if they worsen, then she must call or return. Postpartum depression (choice B) is a depression that occurs in about 10% of postpartum women and it is more serious than the maternity blues. Symptoms may include sleep disturbances and changes in appetite. Postpartum mania (choice C) or postpartum psychosis (choice D) is a psychiatric disorder that occurs in about 1 per 1,000 deliveries. It is characterized by severe anxiety, agitation, disordered thoughts, and confusion. Hospitalization is required. Poststerilization depression (choice E) is a depression that is seen in women following a tubal ligation or other form of permanent sterilization. This patient did not have a sterilization procedure. A 31-year-old woman, gravida 1, para 0, at 36-weeks' gestation with twins comes to the physician for a prenatal visit. The patient has had no contractions, bleeding from the vagina, or loss of fluid, and the babies are moving well. An ultrasound that was performed today shows that the presenting fetus is vertex and the non- presenting fetus is breech. Both fetuses are appropriately grown and greater than 2000 g. The patient wants to know if she should have a vaginal or cesarean delivery. Which of the following is the proper counseling for this patient? A. Both vaginal delivery and cesarean delivery are acceptable. B. Cesarean delivery is mandated because the fetuses are > 2000g. C. Cesarean delivery is mandated because the second twin is breech. D. Vaginal delivery is mandated because the fetuses are > 2000g. E. Vaginal delivery is mandated because the first twin is vertex. Explanation: The correct answer is A. Mode of delivery with twin gestations is an area that has generated controversy over time. Patients with vertex-vertex twins are generally allowed to have a vaginal delivery. Patients with a presenting twin that is non-vertex are generally advised to have a cesarean delivery. Patients with the presenting twin vertex and the non-presenting twin non-vertex may decide which mode of delivery they would prefer. Once the presenting (vertex) twin has delivered, there are essentially 2 options for delivery of the second (non-vertex) twin. The first option is an external cephalic version, in which the head of the second twin is guided into the pelvis so that it becomes a vertex presentation. The second option is a breech extraction of the second twin. Breech extraction may be performed so long as there is an adequate pelvis, a fetal weight greater than 2,000g, an experienced physician, a flexed fetal head, and available general anesthesia. To state that cesarean delivery is mandated because the fetuses are > 2000g (choice B) is incorrect. The fact that the fetuses are > 2000g makes a vaginal delivery with a non-vertex second twin possible. To state that cesarean delivery is mandated because the second twin is breech (choice C) is incorrect. As explained above, vertex-nonvertex twins may be delivered vaginally so long as certain criteria are met. To state that vaginal delivery is mandated because the fetuses are > 2000g (choice D) is incorrect. Vaginal delivery is possible because the fetuses are > 2000g, but the mother may still choose to have a cesarean delivery. To state that vaginal delivery is mandated because the first twin is vertex (choice E) is incorrect. With the first twin vertex, vaginal delivery is possible, but with a non-vertex second twin, cesarean delivery would also be entirely appropriate. A 22-year-old primigravid woman at 8 weeks' gestation comes to the physician for her first prenatal visit. She has had some nausea but no other complaints. She has had no bleeding per vagina or abdominal pain. She had an ovarian cystectomy at age 18 but no other medical or surgical problems. She takes no medications and has no known drug allergies. Examination is unremarkable except for an 8-week-sized non-tender uterus. The patient wants information on vitamin supplementation during pregnancy. Which of the following represents the correct amount of vitamin A supplementation this patient should take daily? A. 10,000 IU B. 25,000 IU C. 50,000 IU D. 100,000 IU E. Vitamin A supplementation during pregnancy is not recommended Explanation: The correct answer is E. Vitamin A is an important vitamin for human reproduction and normal bodily functioning, and vitamin A deficiency is a problem throughout much of the world. In the U.S. and other developed nations, however, the overwhelming majority of women have sufficient stores of vitamin A in the liver. Thus, vitamin A supplementation during pregnancy is not needed or recommended for most women. In fact, vitamin A supplementation has been associated with birth defects, including cranial neural crest malformations. Most commonly used prenatal vitamins contain 5000 IU or less, and this is considered acceptable. Women should be instructed not to take any further supplementation than this. The only exception to this rule is for women who may be vitamin A deficient because of strict vegetarianism or because they are recent emigrants from countries in which vitamin A deficiency is endemic. Recent studies have suggested that vitamin A supplementation with as little as 10,000 IU (choice A) per day may cause birth defects. Therefore, this amount of supplementation should be avoided. The probable teratogenic dose of vitamin A, notwithstanding the abovementioned study, is 25,000 IU (choice B) to 50,000 IU (choice C). Patients should therefore be instructed to avoid these levels. 100,000 IU (choice D) would certainly not be recommended. A 25-year-old woman comes to the physician because of pain and burning with urination. She states that the symptoms started two days ago and have worsened since. She has no fever or chills and has never had these symptoms before. She has hypothyroidism for which she takes thyroid hormone replacement. Otherwise she has no medical problems. Her temperature is 37 C (98.6 F). Examination is unremarkable including a normal pelvic examination. A KOH and normal saline "wet prep" is performed on her vaginal discharge and is negative. Urinalysis reveals numerous white blood cells. Which of the following is the most likely pathogen? A. Escherichia coli B. Neisseria gonorrhoeae C. Pseudomonas species D. Staphylococcus saprophyticus E. Trichomonas vaginalis Explanation: The correct answer is A. This patient has findings that are most consistent with a lower urinary tract infection. A lower urinary tract infection refers to infection of the bladder (cystitis) or urethra (urethritis). The principal complaints for women with lower urinary tract infections are dysuria, urgency, and frequency. Most often examination will be unremarkable. Occasionally, suprapubic tenderness may be present. A urinalysis will often reveal a positive leukocyte esterase or nitrite test. The microscopic analysis will show white blood cells. The most significant risk factors are related to sexual activity and hypoestrogenism. These factors lead to invasion by pathogenic organisms. E. coli is by far the most common causative organism in cases of acute uncomplicated cystitis. It is responsible for approximately 80% of these cases. N. gonorrhoeae(choice B) is often associated with cervicitis and pelvic inflammatory disease. Yet, it can also cause urethritis. However, N. gonorrhoeae is a far less frequent cause of acute uncomplicated cystitis than E. coli. Pseudomonas species (choice C) can cause urinary tract infections. It is often seen in patients with metabolic or anatomic abnormalities. In a routine case of UTI, however, it is not the most common pathogen. Staphylococcus saprophyticus(choice D) is a somewhat common cause of acute, uncomplicated UTIs. It accounts for approximately 10% of cases. Trichomonas vaginalis(choice E) is an organism that is most often associated with vaginitis, but can also cause a urethritis. This patient, however, has a negative normal saline "wet prep." Patients with trichomoniasis usually have visible organisms on the "wet prep." Also, while Trichomonas vaginalis can cause urethritis, it is not nearly as common a cause as is E. coli. A 27-year-old woman comes to the physician because of fevers and back pain. She states that a few days ago she had burning with urination. Over the next few days she developed fevers and chills and a pain on the right side of her back. She has no medical problems and takes no medications. Her temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, pulse is 102/minute, and respirations are 16/minute. Examination shows a patient in mild distress with shaking chills and right costovertebral angle tenderness. Leukocyte count is 18,000/mm3. Urinalysis shows 100 leukocytes/high powered field. Which of the following is the most appropriate next step in management? A. Observation only B. Spinal magnetic resonance imaging (MRI) scan C. Outpatient management with oral trimethoprim-sulfamethoxazole D. Hospital admission and initiation of IV trimethoprim-sulfamethoxazole E. Hospital admission and administration of a 2-week course of IV tetracycline Explanation: The correct answer is D. This patient has a presentation that is most consistent with pyelonephritis. Patients with pyelonephritis typically complain of some combination of back pain, fevers, chills, dysuria, nausea, and vomiting. Examination will often show an elevated temperature, costovertebral angle tenderness, and an elevated leukocyte count. Urinalysis may demonstrate positive nitrite and leukocyte esterase testing. Urine sediment often reveals white blood cells, red blood cells, and white cell casts. Pyelonephritis can be managed on an outpatient basis if the patient is otherwise healthy, has no complicating factors, and is reliable to return if her condition worsens. A patient cannot be managed as an outpatient if there is any evidence of sepsis. This patient, with her high fevers, shaking chills, and elevated leukocyte count may have sepsis and should therefore be admitted to the hospital for intravenous antibiotics. Treatment is with IV trimethoprim- sulfamethoxazole, IV ceftriaxone, IV gentamicin with or without ampicillin, or an IV fluoroquinolone. Once the patient is afebrile, her condition is improving, and she is able to tolerate oral intake, she may be converted to an oral antibiotic regimen to complete a 14-day course. Observation only (choice A) would not be correct for this patient. This patient has pyelonephritis, which is unlikely to resolve without antibiotic therapy. Spinal MRI (choice B) is often used to evaluate patients with back pain. This patient, however, has back pain that is almost certainly related to a renal infection, therefore spinal MRI would not be necessary. Outpatient management with oral trimethoprim-sulfamethoxazole (choice C) is appropriate in some cases of uncomplicated pyelonephritis, as explained above. This patient, however, is quite ill and possibly septic. She, therefore, requires hospital admission. Hospital admission and administration of a 2-week course of IV tetracycline (choice E) would not be appropriate. Tetracycline is not a drug-of-choice in the treatment of pyelonephritis. A 32-year-old woman, gravida 3, para 0, at 29 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. She had a prophylactic cerclage placed at 12 weeks' gestation because of her history of two consecutive 20-week losses. These spontaneous abortions were both characterized by painless cervical dilation, with the membranes found bulging into the vagina on examination . Ultrasound now demonstrates her cervix to be long and closed with no evidence of funneling. Which of the following is the most appropriate time to remove the cerclage from this patient? A. 30-32 weeks B. 32-34 weeks C. 34-36 weeks D. 36-38 weeks E. 38-40 weeks Explanation: The correct answer is D. This patient has a history that is classic for cervical incompetence. Cervical incompetence is characterized by painless cervical dilation, typically in the second or early third trimester. Patients will often have membranes bulging into the vagina. In reality, many patients will present with cervical dilation, but they will also have some cramping or contractions. This can make distinguishing preterm labor from cervical incompetence difficult. Also, cervical incompetence often leads to bulging membranes that then rupture. This rupture of the membranes can also cause contractions and labor such that when the patient presents, the diagnosis of cervical incompetence versus preterm labor is clouded. However, when the diagnosis of cervical incompetence is clear, as it is in this patient, many practitioners favor placing a cerclage (a stitch around the cervix intended to support the pregnancy). This cerclage should be left in place throughout the pregnancy. Only when the patient is at term (36-38 weeks) should the cerclage be removed. To remove the cerclage at 30-32 weeks (choice A), 32-34 weeks (choice B), or 34-36 weeks (choice C) places the patient at risk of iatrogenic prematurity. Say, for example, that the cerclage is removed at 33 weeks, and the patient goes into labor immediately thereafter and delivers. This would result in a 33-week newborn, with risks of intraventricular hemorrhage, respiratory distress syndrome, and necrotizing enterocolitis. This outcome would have been avoided by leaving the stitch in until 36-38 weeks. To remove the cerclage at 38-40 weeks (choice E) runs the risk that the patient may go into labor prior to removal of the stitch. The concern here is that with labor, the stitch will cause a cervical laceration. Therefore, the stitch should be removed prior to the likely onset of labor, but not so early so as to result in a premature newborn if the patient goes into labor with removal of the stitch. Thus, 36-38 weeks is an ideal time for removal of a cerclage. A 32-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the physician for a prenatal visit. She has no current complaints. Her past medical history is significant for hepatitis C infection, which she acquired through a needle stick injury at work as a nurse. She is hepatitis B and HIV negative. She takes no medications and has no allergies to medications. Her prenatal course has been uncomplicated. She wants to know whether she can have contact with the baby or breast-feed given her hepatitis C status. Which of the following is the correct response? A. There is no evidence that breast-feeding increases HCV transmission B. There is strong evidence that breast-feeding increases HCV transmission C. Complete isolation is not needed but breast-feeding is prohibited D. The patient should be completely isolated from the baby E. Casual contact with the baby is prohibited Explanation: The correct answer is A. In the U.S., hepatitis C virus (HCV) is the most common blood-borne infection. HCV is a single-stranded RNA virus that is transmitted by blood-borne transmission or through sexual contact. With the disease being so prevalent—it affects 3.9 million Americans—it is not rare to find a pregnant patient with hepatitis C. In fact, it appears to infect as much as 0.6% of the pregnant population. Studies that have been performed so far show that the rate of infection of infants born to hepatitis C—positive, HIV-negative mothers is about 5%. Hepatitis C transmission through breast milk has not been clearly proven. Breast-fed and bottle-fed infants have a rate of infection that is approximately 4%. Therefore, the patient should be told that casual contact is permitted and that currently there is no evidence that breast- feeding increases HCV transmission to the baby. To state that there is strong evidence that breast-feeding increases HCV transmission to the baby (choice B) is incorrect. As explained above, the available studies do not demonstrate that breast-feeding increases HCV transmission. To state that complete isolation is not needed but breast-feeding is prohibited (choice C) is incorrect for the reasons detailed above. To state that the patient should be completely isolated from the baby (choice D), or that casual contact with the baby is prohibited (choice E) are both incorrect for the reasons detailed above. If patients with hepatitis C were not allowed contact with their infants, they would have to give them up, because hepatitis C is a chronic disease. Fifty percent of patients with HCV develop biochemical evidence of chronic liver disease. Hepatitis C is not like varicella-zoster (chickenpox), where a neonate can be isolated from the mother until she is no longer infectious. A 39-year-old woman, gravida 3, para 2, at term comes to the labor and delivery ward complaining of a gush of fluid. Examination shows her to be grossly ruptured, and ultrasound reveals that the fetus is in vertex presentation. The fetal heart rate is in the 120s and reactive. After a few hours, with no contractions present, oxytocin is started. Three hours later, the tocodynamometer shows the patient to be having contractions every minute and lasting for approximately 1 minute with almost no rest in between contractions. The fetal heart rate changes from 120s and reactive to a bradycardia to the 80s. Sterile vaginal examination shows that the cervix is 6 cm dilated. Which of the following is the most appropriate next step in management? A. Discontinue oxytocin B. Start magnesium sulfate C. Perform forceps assisted vaginal delivery D. Perform vacuum assisted vaginal delivery E. Perform cesarean delivery Explanation: The correct answer is A. This patient has the findings most consistent with uterine hyperstimulation—more than 5 contractions in 10 minutes, contractions lasting 2 minutes or more, or contractions of normal duration occurring within 1 minute of each other and a non-reassuring fetal heart rate tracing. Oxytocin is one of the most frequently used medications in the U.S. It is very effective at producing contractions and used very often for induction of labor. The most common adverse effect with oxytocin is a non-reassuring fetal heart rate pattern brought about by uterine hyperstimulation. Because it has a very short half-life (3-5 minutes), discontinuing the oxytocin often resolves the hyperstimulation quickly. In this patient, with a bradycardia to the 80s, this step is most appropriate. In situations where the fetal heart rate tracing is not as non-reassuring, the oxytocin dosage may be reduced rather than discontinued completely. If uterine hyperstimulation induced by oxytocin does not respond to shutting the oxytocin off, one can start magnesium sulfate (choice B) or give terbutaline. Both of these may be given intravenously to treat uterine hyperstimulation that does not respond to other measures. To perform forceps-assisted (choice C) or vacuum-assisted (choice D) vaginal delivery would be contraindicated. This patient's cervix is only 6 cm dilated. Forceps and vacuum are not used unless the cervix is fully dilated. To perform a cesarean delivery (choice E) would not be appropriate prior to trying other steps. This fetus most likely is not suffering a metabolic acidemia, based on the fact that its reassuring heart rate tracing is in the 120s and reactive. Its bradycardia is directly related to the hyperstimulation, which is caused by the oxytocin. Thus, efforts should be made to manage the fetal distress with conservative measures prior to resorting to cesarean delivery. A 29-year-old female comes to the physician because of fevers and back pain. She is otherwise healthy with no significant past medical history. Examination is significant for a temperature of 38.3 C (101 F), moderate costovertebral angle tenderness, leukocytosis, and white blood cells and red blood cells in the urine. The patients is diagnosed with pyelonephritis and started on intravenous antibiotics. Over the next two days, she rapidly improves, and by hospital day 3, she is tolerating oral intake, voiding without difficulty, feeling no pain, and she has not had a fever for 48 hours. Which of the following is the most appropriate next step in management? A. Continue intravenous antibiotics for 2 weeks B. Discharge home and recommend post-coital prophylaxis C. Discharge home off all antibiotics D. Discharge home to complete a 2-week course of oral antibiotics E. Obtain surgical evaluation Explanation: The correct answer is D. This 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 pain, dysuria, hematuria, frequency, urgency, fevers, chills, nausea, and vomiting. Examination often shows an elevated temperature, costovertebral angle tenderness, leukocytosis, and white cells and red cells in the urine. Completely uncomplicated cases of pyelonephritis can be treated on an outpatient basis. When there are any complicating factors (e.g., concern for sepsis, pregnancy, old age, or other medical illnesses), the patient should be admitted to the hospital for intravenous antibiotics. However, once the patient's condition has improved and she is tolerating oral intake, she may be discharged home to complete a 2-week course of antibiotics. When discharged, however, she should be given strict instructions and precautions regarding the need to return for recurrence of the symptoms or worsening condition. To continue intravenous antibiotics for 2 weeks (choice A) would not be necessary. Once a patient with pyelonephritis is afebrile, doing better, and able to tolerate oral intake, she may be converted to oral antibiotics and be discharged to home. To keep the patient hospitalized for a full 2 weeks would not be necessary. To discharge home and recommend post-coital prophylaxis (choice B) or to discharge home off all antibiotics (choice C) would not be correct. Even though the patient is feeling better, she must still complete a 2- week course of oral antibiotics and not just use antibiotics for post-coital prophylaxis. To obtain surgical evaluation (choice E) would not be necessary. If a patient with pyelonephritis is not improving, then surgical evaluation may be required to determine if another etiology is responsible or to determine if surgical intervention is required. This patient, however, is improving and surgical evaluation would not be necessary. A 27-year-old primigravid woman at 39 weeks' gestation comes to the labor and delivery ward with a gush of fluid and regular contractions. Examination shows that she is grossly ruptured, contracting every 2 minutes, and that her cervix is dilated to 4 cm. The fetal heart rate tracing is in the 140s and reactive. She is admitted to labor and delivery, and over the following 4 hours she progresses to 9 cm dilation. Over the past hour, the fetal heart rate has increased from a baseline of 140 to a baseline of 160. Furthermore, moderate to severe variable decelerations are seen with each contraction. The fetal heart rate does not respond to scalp stimulation. The decision is made to proceed with cesarean delivery. Which of the following is the reason for the cesarean delivery and the preoperative diagnosis? A. Fetal acidemia B. Fetal distress C. Fetal hypoxic encephalopathy D. Low neonatal APGAR scores E. Non-reassuring fetal heart rate tracing Explanation: The correct answer is E. Labor and delivery represents a process of stress for the fetus. With each uterine contraction, blood flow to the placenta decreases, and the fetus is exposed to transient hypoxia. As the labor progresses and more and more contractions occur, this hypoxia can eventually lead to a change from aerobic to anaerobic metabolism. This change can lead to a buildup of acid in the fetus, or fetal acidemia. However, most fetuses tolerate the stress of labor and delivery just fine. The fetus has a variety of protective mechanisms, including a blood buffering system and the diving reflex (a lowering of the heart rate in times of hypoxic stress), to protect it from becoming dangerously acidemic. Electronic fetal monitoring is used to determine whether the fetus is becoming dangerously acidemic or "stressed" during labor so that delivery can occur prior to hypoxic damage to organs. Unfortunately, electronic fetal monitoring is not a very specific tool for identifying fetal acidemia. Many fetuses with a non-reassuring fetal heart rate tracing do not have acidemia and are not in distress. However, it can be very difficult to distinguish non-acidemic fetuses with non- reassuring fetal heart rate tracings from acidemic fetuses with non-reassuring fetal heart rate tracings. Thus, the delivery of many fetuses is expedited because of the concern for fetal acidemia when, in fact, the fetus is not acidemic at all. Thus, it is most accurate to state, as is in this case, that the fetus was delivered because of the non-reassuring fetal heart rate tracing. Fetal acidemia (choice A) is not the reason for delivery. In fact, there is a strong likelihood that this fetus is not acidemic at all. Fetal distress (choice B) is not the reason for delivery. There is a strong likelihood that this fetus is perfectly healthy and will have high neonatal APGAR scores and no distress at all. Fetal hypoxic encephalopathy (choice C) is not the reason for delivery. The desire to prevent hypoxic/acidemic damage to organs, including the brain, is the reason for expediting delivery. However, the non-reassuring fetal tracing does not indicate that hypoxic encephalopathy is necessarily occurring. Low neonatal APGAR scores (choice D) can be a marker of fetal acidemia. However, many fetuses with non-reassuring fetal heart rate tracings do not have low neonatal APGAR scores. A 14-year-old girl comes to the office for a health maintenance evaluation. She is concerned that she has not yet started her menstrual cycle. Her height has increased by 3 inches since her last visit 1 year ago, and her weight is up by 10 pounds. On physical examination, the physician notes a general enlargement of her breasts and areola. Examination of her genital area reveals pubic hair that is coarse and dark and extends past the medial border of the labia. Which of the following is the most likely diagnosis? A. Constitutional delay B. Dysfunctional uterine bleeding C. Dysmenorrhea D. Primary amenorrhea E. Secondary amenorrhea Explanation: The correct answer is A. Constitutional delay is normal pubertal progression at a delayed rate or onset. The average age at menarche is 12 1/2 years, but it may be delayed until 16 or may begin as early as age 10. Dysfunctional uterine bleeding (choice B) results when the endometrium has proliferated under estrogen stimulation, and then begins to slough and causes irregular painless bleeding. This is common in younger adolescents who have not been menstruating long. Dysmenorrhea (choice C) is pain associated with menstrual cycles, and this adolescent is not menstruating yet. Primary amenorrhea (choice D) is a delay in menarche with no menstrual cycles or secondary sex characteristics by 14 years of age or no menses with secondary sex characteristics by 16 years of age. This adolescent has secondary characteristics but is not yet 16 years of age. Secondary amenorrhea (choice E) is the absence of menses for at least three cycles after regular cycles have been present. A 39-year-old woman, gravida 3, para 2, at 40 weeks' gestation comes to the labor and delivery ward after a gush of fluid with regular, painful contractions every two minutes. She is found to have rupture of the membranes and to have a cervix that is 5 centimeters dilated, a fetus in vertex presentation, and a reassuring fetal heart rate tracing. She is admitted to the labor and delivery ward. Two hours later she states that she feels hot and sweaty. Temperature is 38.3 C (101 F). She has mild uterine tenderness. Her cervix is now 8 centimeters dilated and the fetal heart tracing is reassuring. Which of the following is the most appropriate management of this patient? A. Administer antibiotics to the mother after vaginal delivery B. Administer antibiotics to the mother now and allow vaginal delivery C. Perform cesarean delivery D. Perform cesarean delivery and then administer antibiotics to the mother E. Perform intra-amniotic injection of antibiotics Explanation: The correct answer is B. Chorioamnionitis is an infection that can develop at any time before and during delivery. The most common findings in patients with chorioamnionitis are a fever and uterine tenderness. An elevated fetal heart rate is also often seen. This patient has a temperature elevation and uterine tenderness, which make the diagnosis of chorioamnionitis. It is essential that antibiotics be started immediately because prompt initiation of antibiotics, once the diagnosis of chorioamnionitis is made, results in better maternal and neonatal outcomes than if therapy is delayed. It is also essential that broad-spectrum antibiotic therapy be chosen because a mixture of organisms is usually involved including aerobes and anaerobes. The most frequently used regimen is ampicillin or penicillin with gentamicin. In terms of the mode of delivery, vaginal delivery is acceptable in patients with chorioamnionitis. While it is desirable to have an expeditious delivery, chorioamnionitis is not an indication for cesarean delivery. To wait to administer antibiotics to the mother after vaginal delivery (choice A) would not be correct, as the delay would deprive both the mother and the fetus of the beneficial effects of the antibiotics. To perform cesarean delivery (choice C) or to perform cesarean delivery and then administer antibiotics to the mother (choice D) would not be indicated. As explained above, when a woman has chorioamnionitis, it is desirable to expedite delivery, but cesarean delivery should be performed only for obstetric indications. To perform intra-amniotic injection of antibiotics (choice E) would not be indicated. Intra-amniotic injection of antibiotics during labor is not a therapy used to treat chorioamnionitis during labor. A 25-year-old primigravid woman comes to the physician for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had some nausea and vomiting but otherwise has no complaints. Past medical and surgical history are unremarkable. Her family history is significant for cystic fibrosis with an affected aunt. Her husband has an affected cousin. Physical examination is unremarkable. Given her family history, she is concerned about the risks of having a child with cystic fibrosis. She inquires about cystic fibrosis screening. Which of the following is the appropriate response? A. Screening is available B. Screening is inappropriate in her case C. Screening is mandatory D. Screening is not available E. Screening is unnecessary: she has a 1 in 4 chance of having an affected child Explanation: The correct answer is A. Cystic fibrosis (CF) is an autosomal-recessive disease that is common in North American Caucasians of European ancestry. In this population, the frequency of the disease is 1 in 2500 live births. The carrier rate is approximately 1 in 25 individuals. The outcome of patients with CF is highly variable. Some will die in infancy from complications of meconium ileus, whereas others will live beyond the age of 50. The usual clinic manifestations include pulmonary disease with bronchiectasis, pancreatic insufficiency, and failure to thrive. The gene for the disease is known. However, there are more than 500 mutations that can cause CF. The most common mutation, which causes 75% of cases in Caucasians, is referred to as delta-F508. The CF gene has been cloned, and it is possible to perform screening on couples. Genetic techniques can also be used to determine whether the fetus has the relevant mutations. In this patient, with her and her husband's family histories, screening would be available and appropriate. To state that screening is inappropriate in her case (choice B) is incorrect. This patient has relatives with CF and so does her husband. She is concerned about the possibility of having a child with this disease. Screening is available and appropriate in her case. To state that screening is mandatory (choice C) is inappropriate. Whether to undergo screening for a genetic disease is a very personal choice. This patient may not want to know whether she is a carrier or whether her fetus is affected. Many patients with genetic diseases or with family histories of genetic disease feel this way, and screening is certainly not mandatory. To state that screening is not available (choice D) is incorrect. As stated above, CF screening is available. To state that screening is unnecessary because she has a 1 in 4 chance of having an affected child (choice E) is incorrect. If she and her husband were both carriers with the same mutation, the risk would be 1 in 4. However, we do not know this. Although they both have positive family histories, neither may be a carrier. A mother brings her 12-year-old daughter to the physician because the mother is concerned that her child has delayed physical development. In particular, the mother is concerned because her daughter has not yet had a menstrual period. The daughter began developing breasts at age 10, but has not had her first period. The daughter has no medical problems and takes no medications. Examination shows developing breasts and normal external female genitalia. Which of the following is the most appropriate response to the mother? A. Breast development at age 10 is abnormally early. B. Breast development at age 10 is abnormally late. C. Evaluation for late menses should be started immediately. D. Evaluation for late menses should be started at age 15. E. Her child's sexual development is none of her business. Explanation: The correct answer is D. Sexual development is variable from woman to woman, although there are certain ranges of normal. Thelarche, also known as breast-budding, is usually the first sign of secondary sexual development and this occurs on average between the ages of 8 and 10 years of age. The growth spurt usually follows after breast budding and menarche is one of the last stages, occurring, on average, between the ages of 12 and 13. This young woman began developing breasts at age 10, which is entirely appropriate. That she has not had her first menstrual period yet is not abnormal. The general rule is that evaluation for delayed sexual development should be started if there is no breast development by the age of 13 or menses by the age of 15. This general rule can be adapted to fit the circumstances if there are tempo or sequence abnormalities. In this case, with breast development occurring normally and development appearing to proceed in a standard fashion, the mother can be reassured and evaluation for late menses delayed until age 15, if it has not come before that time. To state that breast development at age 10 is abnormally early (choice A) or that breast development at age 10 is abnormally late (choice B) is incorrect. In North America, thelarche occurs, on average, between ages 8 to 10. Therefore, this young woman, who began breast development at age 10, falls into the normal range. To state that evaluation for late menses should be started immediately (choice C) is incorrect. The general rule for evaluation of delayed puberty is that evaluation should take place if thelarche has not occurred by age 13 or menarche by age 15. These ages represent roughly a 2.5 standard deviation from the mean and therefore warrant evaluation. To tell this mother that her child's sexual development is none of her business (choice E) would not be appropriate. While there are certain sexual issues where confidential discussion with an adolescent is appropriate, concerns regarding delayed sexual development are appropriate issues for a parent to be concerned with. A 75-year-old woman comes to the physician because of abdominal distension. She states that she always feels bloated and that she gets full quickly when eating. She has hypertension, for which she takes an angiotensin converting enzyme (ACE) inhibitor, and no other medical problems. Examination shows abdominal distension and a positive fluid wave. Pelvic examination reveals a large, nontender right adnexal mass. Abdominal CT scan demonstrates masses on both ovaries, ascites, and omental caking. CA-125 level is significantly elevated. Serum alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) are negative. Which of the following is the most likely diagnosis? A. Choriocarcinoma B. Cystic teratoma (dermoid) C. Embryonal carcinoma D. Epithelial ovarian cancer E. Sertoli stromal cell tumor Explanation: The correct answer is D. The lifetime incidence of ovarian cancer is 1.4% (1 in 70 women). Unfortunately, there are no early symptoms of ovarian cancer: presenting symptoms have to do with increasing tumor mass. This patient has abdominal discomfort and early satiety, which are often associated with ovarian cancer. Other symptoms that may be seen are fatigue, urinary frequency, and shortness of breath. The most common finding on examination is a pelvic mass, as this patient has. Masses, ascites, and evidence of tumor spread may be seen on CT scan. Roughly 80% of all ovarian cancers are derived from ovarian epithelium. The other major categories of ovarian tumors are germ cell tumors, sex cord stromal tumors, and metastatic tumors. The fact that this patient is 75 years old, has what appears to be ovarian cancer, and has an elevated serum CA- 125 level (seen in approximately 80% of women with epithelial cancers), makes epithelial ovarian cancer most likely. Nongestational choriocarcinoma (choice A) of the ovary is extremely rare. Furthermore, in a patient with choriocarcinoma, the serum hCG should be elevated. Cystic teratoma (dermoid) (choice B) accounts for 25 to 40% of all ovarian neoplasms. However, most teratomas are diagnosed in premenopausal women and they do not usually present as bilateral masses, ascites, and evidence of tumor spread with an elevated serum CA-125 level. Embryonal carcinoma (choice C) is a rare germ cell tumor. Serum AFP and hCG are often elevated with this tumor. Sertoli stromal cell tumor (choice E) is a rare sex cord stromal tumor that exhibits a male or testicular direction of differentiation. A 22-year-old woman comes to the physician for an annual examination. She has normal periods every month and has no complaints. She has no medical problems but does smoke one pack of cigarettes per day. She has intercourse with more than one partner. Examination is unremarkable, including a normal pelvic examination. A Papanicolaou smear shows a high-grade squamous intraepithelial lesion. Which of the following is the most appropriate next step in management? A. Repeat Pap smear in 1 year B. Repeat Pap smear in 6 months C. Perform colposcopy D. Perform a cone biopsy E. Perform a hysterectomy Explanation: The correct answer is C. The Papanicolaou smear is an excellent screening technique for cervical cancer because it is easy to perform, has a relatively low-cost, and is noninvasive. All women who are either sexually active or older than 18 should have annual Pap smears. The downside of the Pap smear is that it has a low sensitivity and high false-negative rate. That is, many women with abnormal cervical cells will have a negative Pap smear. However, if a woman receives an annual Pap smear, it is likely that the lesion will be discovered. Because the progression of cervical dysplasia to cancer takes time, it is believed that these lesions will be discovered early enough to cure them so long as annual screening occurs. This patient has what is called a high-grade squamous intraepithelial lesion (HGSIL). These lesions have a significant risk of eventually progressing to invasive cervical cancer if they are not treated. Therefore, any patient with HGSIL on a Pap smear must undergo colposcopy with directed biopsies so that the lesion can be removed. To 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. This patient has HGSIL and therefore needs much closer follow-up. To repeat the Pap smear in 6 months (choice B) is incorrect. A 6-month follow-up is appropriate for patients with a Pap smear showing atypical squamous cells of undetermined significance (ASCUS), or in some patients with a low-grade squamous intraepithelial lesion (LGSIL). To perform a cone biopsy (choice D) would be incorrect. Prior to surgical management of an abnormal Pap smear result, a tissue diagnosis should be made (Pap smear provides only a cytologic diagnosis). This requires colposcopy with directed biopsies. To perform a hysterectomy (choice E) would not be proper management. Hysterectomy as treatment for HGSIL is generally not indicated. Some patients with recurrent HGSIL, or those with lesions that cannot be properly treated with local therapy, may be candidates for hysterectomy. However, this patient is 22 years old and likely desires future fertility. Also, this is her first HGSIL Pap smear. Therefore, the proper management is to perform a colposcopy. A 55-year-old woman comes to the physician because of hot flashes. She first noted them about 9 months ago, and since then they have been worsening. She states that the flashes come on at various times throughout the day, but that they are especially intense at night. She had her last menstrual period approximately 5 months ago. Her medical history is significant for a pulmonary embolus at the age of 36 and severe depression. She takes fluoxetine for depression and has no allergies to medications but smokes one pack of cigarettes per day. Physical examination is unremarkable, including a normal pelvic examination. Which of the following is the most appropriate pharmacotherapy for this patient? A. Clonidine B. Estrogen and progesterone C. Estrogen only D. Glucophage E. Tamoxifen Explanation: The correct answer is A. This patient has a presentation that is most consistent with perimenopausal hot flashes (or hot flushes as they are sometimes called). The exact pathophysiology that underlies the hot flash is not known. However, it is known that women at the menopause and men that undergo orchiectomies experience these symptoms. Therefore, it is assumed that it is the removal of normal levels of sex steroids from the circulation that results in the hot flash. These hot feelings are experienced as a flushing that can last from several seconds to many minutes. The first-line treatment for most women is with hormone replacement therapy. However, estrogen is contraindicated in this patient given her history of pulmonary embolus. The fact that she is a current smoker also places her at greater risk of developing a thrombus if she were to take hormones. Progestins alone have also been shown to relieve hot flashes; however, they may worsen depression and cause other mood changes in patients. Therefore an alternative treatment is needed for her. Clonidine has been used with some success by many women for relief from hot flashes. It is a blood pressure medication, but it has been shown to be effective against hot flashes when used in low doses. Estrogen and progesterone (choice B) should not be used in this patient because of her history of a pulmonary embolus. Combined hormone replacement therapy has been shown to increase the risk of clot formation in patients. With her history and current smoking, this patient would be at a particularly increased risk. Estrogen only (choice C) would be contraindicated in this patient for two reasons. First, her uterus is still in place, and unopposed estrogen would place her at greater risk for endometrial hyperplasia and cancer. Second, estrogen would increase this patient's risk of thrombus formation. Glucophage (choice D) is an oral hypoglycemic medication used in patients with diabetes. It is not known to be effective for the treatment of hot flashes. Tamoxifen (choice E) actually causes hot flashes in many patients and is not used to treat them. A 16-year-old female comes to the physician because of an increased vaginal discharge. She developed this symptom 2 days ago. She also complains of dysuria. She is sexually active with one partner and uses condoms intermittently. Examination reveals some erythema of the cervix but is otherwise unremarkable. A urine culture is sent which comes back negative. Sexually transmitted disease testing is performed and the patient is found to have gonorrhea. While treating this patient's gonorrhea infection, treatment must also be given for which of the following? A. Bacterial vaginosis B. Chlamydia C. Herpes D. Syphilis E. Trichomoniasis Explanation: The correct answer is B. This patient has a gonorrhea infection. Gonorrhea is one of the most prevalent sexually transmitted diseases (STDs) in the United States. It is more common in patients of lower socioeconomic status, patients with multiple sexual partners, and in urban settings. The causative organism is N. gonorrhoeae, a gram-negative aerobic diplococcus. Up to 80% of women that are infected with the organism will have no symptoms at all or only vague symptoms. Symptoms that are frequently noted are vaginal discharge, postcoital spotting, and urinary symptoms if the urethra is involved. Examination may reveal a cervicitis, although this is not always present. A patient found to have gonorrhea should be treated with intramuscular ceftriaxone or oral cefixime, ofloxacin, or ciprofloxacin. These medications will effectively eradicate the gonococcus. However, because Chlamydia trachomatis can be isolated in up to 50% of women with gonorrhea and because women treated for gonorrhea only may soon go on to develop Chlamydia or pelvic inflammatory disease (PID), any woman receiving treatment for gonorrhea should also be treated for Chlamydia. Treatment of Chlamydia is with azithromycin or doxycycline. It is also essential that this patient's partner be treated as well. When treating a patient for gonorrhea, there is no need to treat the patient with metronidazole to treat bacterial vaginosis (choice A) as well, unless there is evidence of a bacterial vaginosis . Herpes (choice C) often presents as painful vesicles and ulcers. Patients with gonorrhea do not need to be treated for herpes as well, unless there is evidence for herpes infection. Patients with gonorrhea are at increased risk of having other sexually transmitted diseases, including syphilis (choice D). It would be prudent to check this patient for syphilis with a blood test. However, in the absence of a positive syphilis test, patients with gonorrhea do not need to be treated for syphilis. Trichomoniasis (choice E) is treated with metronidazole. Again, as with bacterial vaginosis, herpes, and syphilis, unless there is evidence of Trichomonas infection, the patient does not needed to be treated for trichomoniasis. A 36-year-old woman, gravida 5, para 4, at 30 weeks' gestation comes to the physician for a prenatal visit. She feels the baby moving and has not had bleeding per vagina, contractions, or loss of fluid. The prenatal course has been uncomplicated thus far. The patient is interested in having a postpartum tubal ligation. She has many questions regarding the procedure, including whether there is a risk of failure. Which of the following represents the closest estimate for the likelihood of failure of a postpartum tubal ligation? A. 1 in 10 B. 1 in 100 C. 1 in 1000 D. 1 in 1,000,000 E. There are no reported failures of postpartum tubal ligation. Explanation: The correct answer is B. Postpartum tubal ligation is a highly effective method for giving a woman permanent sterilization. Many methods have been developed, but the most common methods involve doubly ligating a portion of each tube and excising an intervening segment. A postpartum tubal ligation can be performed at the time of cesarean delivery or after a vaginal delivery. If the procedure is performed after a vaginal delivery, a relatively small skin incision is usually made in or near the umbilicus. Patients undergoing postpartum tubal ligation should be warned, however, that the procedure could fail. Failure may result from many factors including recannalization of the tube and poor surgical technique. The most commonly quoted failure rate is about 1 in 100, although a more accurate figure may be closer to 1 in 300. However, it is impossible to give one exact rate, because the risk of failure depends on the patient's age. A 25-year- old woman undergoing tubal ligation is more likely to experience failure than a 40-year-old woman, because the 25-year-old has so many more years of fertility ahead of her. If the failure rate were 1 in 10 (choice A) few doctors would recommend the procedure. For a birth control method to be useful, it must have a low overall failure rate. A failure rate of 10% would be too great to justify the risk of the procedure. 1 in 1000 (choice C) or 1 in 1,000,000 (choice D) are the failure rates that obstetricians would like to see from tubal ligation. Perhaps with time and changes in methodology, the failure rates will continue to fall. At present, however, the most commonly quoted failure rate is 1 in 100. To state that there are no reported failures of postpartum tubal ligation (choice E) is absolutely incorrect. Patients need to be cautioned that the procedure can fail and that if pregnancy is suspected, they should notify their doctor immediately, as the risk of ectopic pregnancy after tubal ligation is significant. A 26-year-old primigravid woman at 35 weeks' gestation comes to the labor and delivery ward because of painful uterine contractions and a gush of fluid. Sterile speculum examination reveals a pool of clear fluid in the vagina that is nitrazine positive. When the fluid is examined under the microscope, a "ferning" pattern is seen. Cervical examination shows the patient to be 4 cm dilated, 100% effaced, and at 0 station. Fetal fingers can be felt along side the fetal head. External uterine monitoring shows contractions every 2 minutes. External fetal monitoring shows the fetal heart rate to be in the 130s and reactive. Which of the following is the most appropriate next step in management? A. Expectant management B. Oxytocin augmentation C. Forceps delivery D. Vacuum delivery E. Cesarean section Explanation: The correct answer is A. This patient has a compound presentation, which happens when an extremity prolapses alongside the fetal presenting part. In this case, the compound presentation is the fetal vertex along with a fetal arm. Compound presentation occurs in approximately 1 in 1000 deliveries and is brought about when the pelvic inlet is not completely occluded by the fetal head. Most often this occurs with premature fetuses. A compound presentation can be allowed to undergo a normal labor and delivery. The prolapsed arm should be left alone, as it will not interfere with the labor and delivery in most cases. Often the arm will rise out the way as the vertex descends further. Oxytocin augmentation (choice B) would not be appropriate management. This patient is in active labor, with painful contractions every 2 minutes and 4 cm of cervical dilation. Oxytocin is used in cases in which there is a need to augment labor (e.g., when contractions are not adequate) or to induce labor (e.g., when there are no contractions present.) This patient has adequate contractions. Forceps delivery (choice C) is not indicated at this point. The patient's cervix is not fully dilated, and the presence of the fetal arm, if it persists, would prevent proper application of the forceps. Vacuum delivery (choice D) would not be appropriate. As with forceps, vacuum is not used unless the cervix is fully dilated and the vertex is at +2 to +3 station. This patient is only 4 cm dilated, and the vertex is at 0 station. There is no fetal or maternal indication at this point for vacuum delivery. Cesarean delivery (choice E) is not indicated. As noted above, most women with a compound presentation, with a hand presenting by the fetal head, can undergo a normal labor and delivery. A 19-year-old female comes to the physician because of left lower quadrant pain for 2 months. She states that she first noticed the pain 2 months ago but now it seems to be growing worse. She has had no changes in bowel or bladder function. She has no fevers or chills and no nausea, vomiting, or diarrhea. The pain is intermittent and sometimes feels like a dull pressure. Pelvic examination is significant for a left adnexal mass that is mildly tender. Urine hCG is negative. Pelvic ultrasound shows a 6 cm complex left adnexal mass with features consistent with a benign cystic teratoma (dermoid). Which of the following is the most appropriate next step in management? A. Repeat pelvic examination in 1 year B. Repeat pelvic ultrasound in 6 weeks C. Prescribe the oral contraceptive pill D. Perform hysteroscopy E. Perform laparotomy Explanation: The correct answer is E. This patient has a presentation and findings that are most consistent with a benign cystic teratoma (dermoid). Dermoids are a type of ovarian germ cell tumor. Germ cell tumors are the most common type of ovarian neoplasm in females under the age of 20 and dermoids are the most common benign ovarian neoplasm. Dermoids can range in size from small masses that are noted incidentally on ultrasound and cause no symptoms, to large cysts that cause pain and pressure, as this patient has. Laparotomy is the most appropriate next step in the management of this patient because, as adnexal masses enlarge-- especially when they become greater than 5 cm--the risk of ovarian torsion increases. Thus, laparotomy with removal of the dermoid is indicated to prevent torsion. Also, this patient's mass is causing her symptoms of pain and pressure and, on that basis, should be removed. Finally, while the mass most likely is a dermoid, this is not certain without pathologic diagnosis and, therefore, the cyst should be removed and evaluated by a pathologist. At the time of surgery, close examination should be made of the other ovary because dermoids may be found bilaterally in more than 10% of cases. To repeat pelvic examination in 1 year (choice A) would not be correct management. This patient is symptomatic with a 6 cm ovarian mass that is at risk for torsion. She should, therefore, be managed surgically. To repeat pelvic ultrasound in 6 weeks choice B) is appropriate for some adnexal masses. For example, in a young woman with a small complex cyst that appears consistent with a corpus luteum, it may be most prudent to recheck an ultrasound in 6 weeks to see if the cyst has resolved. This patient, however, is symptomatic with a 6 cm cyst that appears to be a dermoid, which will not resolve spontaneously. She, therefore, requires surgery. To prescribe the oral contraceptive pill (choice C) may help to prevent future ovarian cysts but it will not resolve this cyst, which requires surgical management. To perform hysteroscopy (choice D) would not be indicated. Hysteroscopy is used to evaluate the uterine cavity and would not be used for management of an adnexal mass. A 34-year-old woman comes the physician because of lower abdominal cramping. The cramping started 2 days ago. Examination is unremarkable except for a pelvic examination that reveals a 10-week sized uterus. Urine hCG is positive, and pelvic ultrasound reveals a 10-week intrauterine pregnancy with a fetal heart rate of 160. The patient states that she is not sure whether to keep the pregnancy. Which of the following is the most appropriate next step in management? A. Counsel the patient or refer to an appropriate counselor B. Notify the patient's parents C. Notify the patient's partner D. Schedule a termination of pregnancy E. Tell the patient that she is likely to have a miscarriage Explanation: The correct answer is A. The decision of whether to have a termination of pregnancy is a deeply personal one. This patient has just been notified that she is pregnant with a 10-week fetus. She is unsure whether she wants to keep her pregnancy or terminate it. In this setting, the most appropriate next step is to counsel the patient regarding her options or refer the patient for counseling. In a balanced way, the patient should be fully informed of all of her options including raising the child herself, placing the child up for adoption, and abortion. To notify the patient's parents (choice B) is not appropriate. Such an act would violate the patient's confidentiality. A 34-year-old woman is an adult and issues of parental notification do not apply. To notify the patient's partner (choice C) is not appropriate. This notification would also violate confidentiality. To schedule a termination of pregnancy (choice D) would not be appropriate. This patient has just informed the physician that she is unsure what she wants to do. To just go ahead and schedule the termination without proper counseling of the patient would not be a balanced or proper approach for the patient. To tell the patient that she is likely to have a miscarriage (choice E) is inappropriate. This patient may have a miscarriage, as might any patient with a first-trimester pregnancy. However, once an intrauterine pregnancy with fetal cardiac activity is identified, the risk of miscarriage is approximately 10%. Therefore, she is most likely not to have a miscarriage. A 20-year-old female comes to the physician because she has never had a period. She has no medical problems, has never had surgery, and takes no medications. Examination shows that she is a tall female with long extremities. She has normal size breasts, although the areolas are pale. She has little axillary hair. Pelvic examination is significant for scant pubic hair and a short, blind-ended vaginal pouch. Which of the following is the most appropriate next step in the management of this patient? A. No intervention is necessary B. Bilateral gonadectomy C. Unilateral gonadectomy D. Bilateral mastectomy E. Unilateral mastectomy Explanation: The correct answer is B. This patient has the findings that are most consistent with androgen insensitivity syndrome (formerly called testicular feminization syndrome). This syndrome results from genetic defects leading to abnormal androgen receptor function. Patients with androgen insensitivity syndrome are genotypically males (46, XY) but phenotypically females-with breasts and no external male genitalia. The reason that breasts develop is that estrogens, which are expressed at puberty and which also result from peripheral conversion of androgens, act upon the breast tissues unopposed by androgens because of the androgen receptor defect. This unopposed estrogen leads to breast growth and the resultant breasts are normal sized, although they have undeveloped nipples and pale areolae. There are no internal female organs, because mullerian-inhibiting substance is present during development. There are no external male organs because of the androgen receptor defect. Testicles do exist, but they are intra-abdominal. The gonads have a high rate of malignant degeneration in patients with androgen insensitivity syndrome and therefore, after puberty, they should be removed via bilateral gonadectomy. It is important to wait until after puberty so that full development can take place. To state that no intervention is necessary (choice A) is incorrect. If the gonads are not removed from a patient with androgen insensitivity syndrome there is a significant risk that the patient will develop a gonadal malignancy. To perform a unilateral gonadectomy (choice C) is incorrect. To leave one of the gonads in would still run the risk of malignant degeneration in that gonad. Once puberty has taken place, therefore, both gonads should be removed. To perform a bilateral mastectomy (choice D) or a unilateral mastectomy (choice E) would be incorrect. In patients with androgen insensitivity syndrome (testicular feminization syndrome) the primary concern is for gonadal malignancy and not breast malignancy. A 33-year-old primigravid woman at 18 weeks' gestation comes to the physician for a prenatal visit. Her prenatal course has been uncomplicated thus far. She has no complaints. She has had no loss of fluid, bleeding, or contractions. She has hypothyroidism, for which she takes thyroid hormone replacement. The patient states that a friend of hers recently had a preterm delivery. The patient is quite concerned about preterm delivery and wants to know whether home uterine activity monitoring (HUAM) is recommended. Which of the following is the most appropriate response? A. HUAM has been proven to cause preterm birth B. HUAM has been proven to prevent preterm birth C. HUAM has not been proven to prevent preterm birth D. HUAM should be started immediately E. HUAM should be started at 35 weeks Explanation: The correct answer is C. Home uterine activity monitoring (HUAM) became a controversial area of obstetrics during the 1990s. Of all liveborn neonates, approximately 7% will be less than 2500 g (low birth weight). Approximately 1% will be less than 1500 g (very low birth weight). Most of the infant mortality rate comes from these low birth weight and very low birth weight neonates. Preterm labor and delivery is the cause of many of these cases. Thus, strategies to prevent preterm delivery are very much sought after. One such strategy is HUAM. With this technique, women are monitored at home with a tocodynamometer (a way to measure uterine contractions). The theory is that this home monitoring will allow for preterm labor to be recognized and treated in its earliest stages, which may help to prevent preterm births. In practice, however, this has not been proven to be the case. Numerous studies have been performed, and HUAM has not been proven to prevent preterm birth. A possible benefit of HUAM may be the early recognition of preterm labor, which would allow for the administration of corticosteroids to bring about fetal pulmonary maturity, even if a preterm delivery could not be prevented. This question has not been fully answered. At present, therefore, HUAM has not been proven to prevent preterm birth, and its use is not recommended. To state that HUAM has been proven to cause preterm birth (choice A) is not correct. HUAM is a noninvasive technique for monitoring uterine activity, and it is used to try to prevent preterm birth. Side effects and complications are rare. To state that HUAM has been proven to prevent preterm birth (choice B) is incorrect. This is the central area of controversy for this technique, namely that it has not been proven to prevent preterm birth. To state that HUAM should be started immediately (choice D), or that HUAM should be started at 35 weeks (choice E) is incorrect. As explained above, HUAM has not been proven to prevent preterm delivery; therefore, its use is not currently recommended. A 26-year-old primigravid woman at 12 weeks' gestation comes to the physician because of pain and swelling in her right thigh. She first noted the onset of the pain 2 days ago, and since then it has grown worse. An ultrasound study performed on her lower-extremity venous system reveals evidence of a proximal thrombus in the right leg. She is started on low-molecular-weight heparin injections. Which of the following is an advantage of low-molecular-weight heparin compared with unfractionated heparin? A. Low-molecular-weight heparin has a shorter half-life B. Low-molecular-weight heparin is cheaper C. Low-molecular-weight heparin is less likely to cause birth defects D. Low-molecular-weight heparin is less likely to cause thrombocytopenia E. Low-molecular-weight heparin is less likely to cross the placenta Explanation: The correct answer is D. This patient has a deep venous thrombosis (DVT) in her right lower extremity. Pregnancy is a risk factor for the development of DVTs because of alterations in coagulation factors, venous stasis, and, often, decreased physical activity. It is essential that DVT during pregnancy be treated so that the thrombus does not proliferate or embolize and so that new thrombi do not form. Coumadin is contraindicated during the first trimester because of the risk of birth defects in fetuses exposed to this drug. Coumadin embryopathy is a syndrome consisting of nasal hypoplasia and stippled vertebral and femoral epiphyses. Second- and third-trimester exposure to Coumadin can lead to hydrocephaly, microcephaly, ophthalmologic abnormalities, fetal growth retardation, and developmental delay. Low-molecular-weight heparin has been shown to be an excellent anticoagulant because it has a longer half-life and a more predictable dose- response relationship compared with unfractionated heparin, which allows once- or twice-daily dosing without the need for frequent laboratory monitoring of the prothrombin time and activated partial thromboplastin time. Low-molecular-weight heparin is also less likely to cause thrombocytopenia and hemorrhagic complications than unfractionated heparin. Low-molecular-weight heparin does not have a shorter half-life (choice A) than unfractionated heparin. In fact, low-molecular-weight heparin has a longer half-life, and it is this quality that allows for once- or twice-daily dosing. Low-molecular-weight heparin is not cheaper (choice B) than unfractionated heparin. Low- molecular-weight heparin itself is more expensive, but there is a cost advantage in that less frequent laboratory monitoring is needed. Neither low-molecular-weight heparin nor unfractionated heparin is likely to cause birth defects (choice C). Neither crosses the placenta (choice E) and neither is associated with teratogenesis. A 31-year-old, HIV-positive woman, gravida 3, para 2, at 32-weeks' gestation comes to the physician for a prenatal visit. Her prenatal course is significant for the fact that she has taken zidovudine throughout the pregnancy. Otherwise, her prenatal course has been unremarkable. She has no history of mental illness. She states that she has been weighing the benefits and risks of cesarean delivery in preventing transmission of the virus to her baby. After much deliberation, she has decided that she does not want a cesarean delivery and would like to attempt a vaginal delivery. Which of the following is the most appropriate next step in management? A. Contact psychiatry to evaluate the patient B. Contact the hospital lawyers to get a court order for cesarean delivery C. Perform cesarean delivery at 38 weeks D. Perform cesarean delivery once the patient is in labor E. Respect the patient's decision and perform the vaginal delivery Explanation: The correct answer is E. Cesarean delivery has been shown to decrease the rate of transmission of HIV from an infected mother to her fetus. Some reports have shown that the transmission rate can be decreased to as low as 2% with the combination of antiretroviral medication and elective cesarean delivery prior to labor or rupture of membranes. However, although cesarean delivery benefits the infant by decreasing the risk of transmission, the risks of the surgery accrue to the mother. Risks of cesarean delivery include bleeding, infection, and injury to internal organs. HIV-infected women with low CD4 cell counts are known to have higher rates of postoperative complications. Thus, the decision of whether to have a cesarean ultimately belongs to the mother. This patient's autonomy must be respected and she should have a vaginal delivery if she so chooses. To contact either psychiatry to evaluate the patient (choice A) or the hospital lawyers to get a court order for cesarean delivery (choice B) would be incorrect. Patient autonomy must be respected when it comes to the decision of whether to have a cesarean delivery. This patient has weighed the benefits and risks and has put a great deal of deliberation into her decision. There is no need to involve the psychiatry department or the hospital lawyers in this decision. To perform cesarean delivery at 38 weeks (choice C) or once the patient is in labor (choice D) would not be correct. In HIV-positive women who do want an elective cesarean delivery, the delivery should be performed at 38 weeks to avoid the risk of labor or rupture of membranes. Once labor starts or the membranes are ruptured, the risk of HIV transmission increases. However, this patient does not want a cesarean delivery, so that operation should not be performed. A 26-year-old primigravid woman at 42 weeks' gestation comes to the labor and delivery ward for induction of labor. The prenatal course was significant for a positive group B Streptococcus culture performed at 35 weeks. Antenatal testing over the past 2 weeks has been unremarkable. The patient is started on lactated Ringer's IV solution. Sterile vaginal examination shows that the patient's cervix is long, thick, and closed. Prostaglandin (PGE2) gel is placed into the vagina, and electronic fetal heart rate monitoring is continued. In approximately 60 minutes, the fetal heart rate falls to the 90s, as the tocodynamometer shows the uterus to be contracting every 1 minute with essentially no rest in between contractions. Which of the following was most likely the cause of the uterine hyperstimulation? A. Infection B. IV fluids C. Postdates pregnancy D. Prostaglandin (PGE2) gel E. Vaginal examination Explanation: The correct answer is D. Prostaglandin (PGE2) gel is widely used for labor induction. In simple terms, it is used "to soften" an unfavorable cervix, to make the cervix more favorable for induction. It has been shown to lead to an improvement in the Bishop's score, a shorter duration of labor, a need for lower maximal doses of oxytocin, and a reduced incidence of cesarean deliveries. PGE2 gel can also cause uterine contractions. One of the major side effects with PGE2 gel is uterine hyperstimulation. This occurs when uterine contractions come one right after the other, or when there is a tetanic contraction (a prolonged uterine contraction with no rest period). In this setting, the fetus can become hypoxic with a resultant bradycardia. This patient had the gel placed and 60 minutes later had uterine hyperstimulation. Infection (choice A) has not been shown to cause uterine hyperstimulation. This patient's group B Streptococcus colonization is likely noncontributory. IV fluids (choice B), unless oxytocin is present, do not cause uterine hyperstimulation. Postdates pregnancy (choice C) is the reason for this patient's induction and not likely the direct cause of her uterine hyperstimulation. Vaginal examination (choice E) does not usually cause uterine hyperstimulation. Vaginal examination with a cervical examination can be used for fetal scalp stimulation—rubbing the baby's head to provoke an acceleration of the fetal heart rate. However, this does not usually provoke uterine hyperstimulation. A 29-year-old woman comes to the emergency department because of abdominal distension and shortness of breath. Approximately 1 week ago, she underwent fertility treatment with ovulation induction and oocyte retrieval. She has a history of polycystic ovarian syndrome but no other medical problems. She had laparoscopy 1 year ago as part of a fertility evaluation. She has no known drug allergies. Her temperature is 37 C (98.6 F), blood pressure is 80/40 mm Hg, pulse is 130/min, and respirations are 28/min. Physical examination is remarkable for crackles at the lung bases bilaterally and a distended, nontender abdomen with a fluid wave. Ultrasound demonstrates bilaterally enlarged ovaries (each >10 cm) and free fluid in the abdomen. Urine hCG is negative. Which of the following is the most likely diagnosis? A. Ectopic pregnancy B. Hemorrhagic ovarian cyst C. Ovarian hyperstimulation syndrome D. Ovarian torsion E. Tubo-ovarian abscess Explanation: The correct answer is C. This patient has a presentation that is most consistent with ovarian hyperstimulation syndrome (OHSS). OHSS most often occurs in patients undergoing ovulation induction with gonadotropins, although it can also occur with use of clomiphene citrate. The signs and symptoms of OHSS run a spectrum depending on whether the disease is mild, moderate, or severe. In mild OHSS, the ovaries are less than 5 cm, and the patient has mild weight gain and pelvic discomfort. In moderate OHSS, the ovaries can be up to 10 cm in diameter, and the patient has at least a 10-pound weight gain, nausea, and vomiting. In severe OHSS, the ovaries are greater than 10 cm, with ascites, hydrothorax, hemoconcentration, and oliguria. Management depends on the severity of the syndrome, with mild cases being managed conservatively and more severe cases being managed more aggressively with the possible need for paracentesis, thoracentesis, or surgery. Pelvic or abdominal examinations should not be performed if OHSS is on the differential diagnosis because examination can lead to rupture of the ovarian capsule. Evaluation should be done with a careful ultrasound examination. Ectopic pregnancy (choice A) can cause abdominal distension. However, this patient has a negative hCG, which effectively rules out pregnancy. A hemorrhagic ovarian cyst (choice B) can also cause abdominal distension. However, with a hemorrhagic cyst, pain is most often the presenting complaint. The distension is usually caused by intraperitoneal bleeding, which causes significant pain and tenderness on examination. This patient has no tenderness on examination. Ovarian torsion (choice D) causes significant pain. Abdominal pain and tenderness are not the predominant features of this patient's presentation. Tubo-ovarian abscess (choice E) causes significant pain and often a fever. This patient is afebrile, with no abdominal tenderness. A 22-year-old woman, gravida 3, para 2, at 22 weeks' gestation comes to the physician because of an ulcer near her vagina. She noted this a few days ago and it has not improved. The ulcer is painless. The patient has no history of medical problems and takes no medications. She is allergic to penicillin. Examination is significant for a 22 week-sized uterus and a 1 cm, raised, nontender lesion on the distal portion of the vagina. A rapid plasma reagin (RPR) test is sent; the result is positive. A microhemagglutination assay for Treponema pallidum (MHA-TP) is also read as positive. Which of the following is the most appropriate management for this patient? A. Administer erythromycin B. Administer levofloxacin C. Administer metronidazole D. Administer tetracycline E. Desensitize the patient and then administer penicillin Explanation: The correct answer is E. This patient has a presentation that is consistent with primary syphilis. Syphilis is caused by the organism Treponema pallidum, which is a highly contagious spirochete. The incubation period for the organism is anywhere from 10 to 90 days, after which a chancre, which is a raised, painless ulcer, will appear. T. pallidum cannot be cultured, but it can be identified with darkfield microscopy or fluorescent antibody staining from obvious lesions. Serologic tests can also be used, such as the RPR and VDRL tests, which are not specific for T. pallidum infection and may be positive in patients with collagen vascular disease, intravenous drug abuse, bacterial and viral infections, a history of blood transfusions, and even pregnancy. Because the RPR and VDRL are not specific, a treponemal specific assay such as the FTA-ABS or MHA-TP should also be used for confirmation. When these are positive and the patient has no history of treatment, it is absolutely essential that treatment be given because syphilis in pregnancy is associated with a number of complications including fetal demise, IUGR, preterm delivery, and congenital infection. Treatment during pregnancy must be with penicillin as no other drug permits safe and effective treatment of the fetus as well as the mother. In a patient who is allergic to penicillin, oral desensitization must be performed first in a hospital setting with appropriate facilities. To administer erythromycin (choice A), levofloxacin (choice B), or metronidazole (choice C) would not be proper management. These are not drugs that will effectively treat syphilis in pregnancy. Furthermore, levofloxacin is contraindicated during pregnancy, as are all fluoroquinolones, because of the possible relationship between maternal use and arthropathies in the offspring. To administer tetracycline (choice D) would be appropriate in the non-pregnant patient with syphilis who is allergic to penicillin. Tetracycline is considered a reasonable alternative in that situation. However, in the pregnant patient, tetracycline cannot be used because of effects on the fetal teeth and bones. Only penicillin is considered adequate for the treatment of syphilis in pregnancy. A 32-year-old, HIV-positive, primigravid woman comes to the physician for a prenatal visit at 30 weeks. Her prenatal course has been notable for her use of zidovudine (ZDV) during the pregnancy. Her viral load has remained greater than 1000 copies per milliliter of plasma throughout the pregnancy. She has no other medical problems and has never had surgery. Examination is appropriate for a 30-week gestation. She wishes to do everything possible to prevent the transmission of HIV to her baby. Which of the following is the most appropriate next step in management? A. Offer elective cesarean section after amniocentesis to determine lung maturity B. Offer elective cesarean section at 38 weeks C. Offer elective cesarean section at 34 weeks D. Recommend forceps-assisted vaginal delivery E. Recommend vaginal delivery Explanation: The correct answer is B. A significant body of evidence has developed that transmission rates of HIV from mother to infant can be decreased through the use of medications and cesarean delivery. The Pediatric AIDS Clinical Trials Group (PACTG) 076 Zidovudine Regimen was shown to decrease the rate of transmission from 25% to 8%. This regimen consisted of ZDV being given antepartum and intrapartum to the mother and postpartum to the infant. More recent evidence is accumulating that the mode of delivery also affects transmission rates. The combination of ZDV therapy and cesarean delivery decreases the risk of transmission to approximately 2%. But, the decrease in transmission with cesarean delivery occurs regardless of whether the patient is receiving antiretroviral therapy. Thus, cesarean delivery should be offered to HIV- positive women to prevent transmission. Delivery at 38 weeks is recommended to reduce the chances that the patient will go into labor or rupture her membranes. Once these occur, the benefit of cesarean delivery is reduced. To offer elective c-section after amniocentesis to determine lung maturity (choice A) is incorrect. Amniocentesis should be avoided, if possible, in the HIV-positive woman. To offer elective c-section at 34 weeks (choice C) is incorrect. To perform a cesarean delivery at 34 weeks risks iatrogenic prematurity in the neonate. Cesarean delivery prior to the onset of labor or rupture of membranes is the preference, and this can be accomplished at 38 weeks with a lower risk of iatrogenic prematurity. To recommend forceps-assisted vaginal delivery (choice D) or vaginal delivery (choice E) is incorrect. The decision of which mode of delivery to choose ultimately belongs to the patient. But, vaginal delivery would not be recommended, as cesarean delivery has been shown to decrease transmission rates. A 12-year-old female comes to the physician because of a vaginal discharge. The discharge started about 2 months ago and is whitish in color. There is no odor. The patient has no complaints of itching, burning, or pain. The patient started breast development at 9 years of age and her pubertal development has proceeded normally to this point. She has not had her first menses and she is not sexually active. She has no medical problems. Examination is normal for a 12-year-old female. Microscopic examination of the discharge shows no evidence of pseudohyphae, clue cells, or trichomonads. Which of the following is the most likely diagnosis? A. Bacterial vaginosis B. Candida vulvovaginitis C. Physiologic leukorrhea D. Syphilis E. Trichomoniasis Explanation: The correct answer is C. Physiologic leukorrhea can be seen during 2 different periods of childhood. Some female neonates develop a physiologic leukorrhea shortly after birth as maternal circulating estrogens stimulate the newborn's endocervical glands and vaginal epithelium. The discharge in these neonates is often gray and gelatinous. Physiologic leukorrhea can also be seen during the months preceding menarche. During this time, rising estrogen levels lead to a whitish discharge not associated with any symptoms of irritation. This patient has a whitish discharge, no other symptoms, and she has had normal pubertal development up to this point. The discharge itself has no characteristics of infection. Therefore, physiologic leukorrhea is the most likely diagnosis. Bacterial vaginosis (choice A) is not the most likely diagnosis in this patient because the discharge is not malodorous and there are no clue cells seen on microscopic examination of the discharge. Candida vulvovaginitis (choice B) is not the most likely diagnosis because the discharge is not thick and white (or "cottage-cheese"-like) and the patient has no irritative symptomatology. Syphilis (choice D) most often presents with a painless ulcer (called a chancre) or is found with serologic testing. A nonmalodorous, whitish vaginal discharge in a 12-year-old female who is not sexually active is almost certainly not evidence of syphilis. Trichomoniasis (choice E) is also highly unlikely in this patient and the lack of trichomonads on the microscopic examination effectively rules out this diagnosis. A 33-year-old woman comes to the physician because she has not had a menstrual period for 8 months. She had menarche at the age of 12 and, after a few years of irregular menses, has since had normal monthly menses. She has no medical problems and takes no medications. Examination reveals a normal- appearing female with no abnormalities noted. Urine human chorionic gonadotropin (hCG) is negative. Serum thyroid stimulating hormone (TSH) and prolactin are also normal. The patient is given a 10-day course of medroxyprogesterone acetate. Upon completing the 10 days, she has a heavy menstrual period. This patient's withdrawal bleeding in response to the progesterone provides good evidence for which of the following? A. Asherman syndrome B. Endogenous estrogen production C. Endometrial carcinoma D. Menopause E. Pregnancy Explanation: The correct answer is B. Primary amenorrhea is defined as the lack of spontaneous uterine bleeding by the age of 16. Secondary amenorrhea is defined as the absence of a menstrual period for 6 months or more in a woman who previously had normal periods or the absence of menses for 12 months or more in women with previously irregular menstrual periods. This patient, given that she previously had normal menstrual periods, has secondary amenorrhea. The most common cause of missed menses in previously cycling women is pregnancy. Therefore, it is absolutely essential that a pregnancy test be performed on any woman with this complaint. Hyperprolactinemia is the cause of amenorrhea in 10 to 20% of cases, so it is also important that a prolactin level be checked. And, because thyroid dysfunction can also cause a loss of menses, a TSH should also be checked. This patient, however, is not pregnant and has normal TSH and prolactin levels. At this point, some physicians would perform a progesterone withdrawal test. This consists of giving a woman an intramuscular injection of progesterone or oral progesterone for 5 to 10 days and then checking to see if the patient has withdrawal menstrual bleeding. If withdrawal bleeding occurs within 7 days, then patients are assumed to have adequate levels of endogenous estrogen production. Most patients with amenorrhea, adequate endogenous estrogen production, and withdrawal bleeding after the administration of progestins will have some form of polycystic ovarian syndrome (PCOS). Asherman syndrome (choice A) describes the condition in which menstrual periods do not occur because the uterine cavity has become obliterated with adhesions. These adhesions result from trauma to the basal level of the endometrium, most often occurring at the time of dilation and curettage. Patients with this syndrome would not be expected to have menses in response to progesterone. Endometrial carcinoma (choice C) typically presents with heavy, irregular bleeding or as postmenopausal bleeding. Menopause (choice D) represents the loss of menstrual periods as ovarian function decreases. Postmenopausal patients would not be expected to have withdrawal menses after progesterone exposure. This patient's bleeding does not provide good evidence of pregnancy (choice E). Her negative urine hCG and withdrawal bleeding after progesterone make it extremely unlikely that she is pregnant. A 25-year-old woman, gravida 2, para 2, comes to the physician to discuss birth control options. She and her partner have tried to use condoms; however, they find it difficult to use them consistently and she would like to try another form of contraception. She has no medical problems, takes no medications, and has no family history of cancer. Her examination is within normal limits. After a discussion with the physician, she chooses to take the oral contraceptive pill (OCP). She stays on the pill for the next three years. She now has most significantly decreased her risk of developing which of the following malignancies? A. Bone cancer B. Breast cancer C. Cervical cancer D. Endometrial cancer E. Liver cancer Explanation: The correct answer is D. Numerous studies have demonstrated that use of the oral contraceptive pill significantly decreases a woman's likelihood of developing endometrial cancer. Overall, use of the oral contraceptive pill appears to decrease the risk by approximately 50%, with greatest effects in those using the pill for more than 3 years. One theory to explain the decreased endometrial cancer risk in oral contraceptive users is that the oral contraceptive pill provides almost continuous exposure of the endometrium to progestins. The major factor in the development of endometrial cancer is estrogen exposure, whether endogenously (e.g., due to obesity or chronic anovulation) or exogenously (e.g., from unopposed estrogen replacement therapy). By providing almost daily exposure to progestins, the oral contraceptive pill works to counteract the effects of estrogens. Over time, women on the OCP develop thinner endometrial linings and have a lower risk of developing endometrial cancer. There is no clear relationship between bone cancer (choice A) and OCP use. The relationship between breast cancer (choice B) and oral contraceptives remains unclear at this time. There is some evidence that current users and those who have recently stopped may be at some increased risk of breast cancer. However, there is also evidence that when breast cancer is diagnosed in an oral contraceptive user, it tends to be more localized than in a nonuser. The relationship between cervical cancer (choice C) and the OCP also remains unclear at this time. Overall the results have been inconclusive. All sexually active patients should have regular screening for cervical dysplasia with a Pap smear starting at age 18 or with the onset of sexual intercourse. The OCP does not protect against liver cancer (choice E). The OCP is believed to increase the risk of certain benign liver tumors. A 38-year-old woman comes to the physician for an annual examination and Pap smear. She has no complaints. She has a regular period every month. She is sexually active with her husband. She has migraine headaches and is status post a tubal ligation. She states that she uses numerous alternative medications for mood, sleep, and disease prevention. Examination, including pelvic and breast examination, is unremarkable. Which of the following is an appropriate question to ask this patient? A. Does your husband know you are using these alternative medications? B. Do you realize how dangerous alternative medicines are? C. Which alternative medications do you use? D. Why don't you stick with traditional medicines? E. Why haven't you revealed your use of alternative medications before? Explanation: The correct answer is C. Some estimates indicate that roughly 50% of Americans use some forms of complementary and alternative medicine (CAM). The categories of these include mind-body interventions, such as yoga, alternative systems of medical practice such as Chinese medicine, pharmacologic treatments such as medicinal plants, herbal medicine such as St. John's wort, diet therapies such as vegetarianism, manual healing methods such as massage, and bioelectromagnetic applications such as magnets for musculoskeletal pain. It is essential for the physician to work with the patient regarding the use of CAM. The first step is to find out which methods the patient uses. This patient has told the physician that she uses alternative medications. Many patients do not offer this information, assuming that the usual physician will not support CAM. It is therefore important to ask the patient whether she is using, or considering using, CAM. Because the field of CAM is so broad, it is essential to ask which types of CAM the patient uses. One cannot assume that all alternative therapies are equivalent. Thus, the most appropriate question to ask this patient is "Which alternative medications do you use?" This is a non-threatening question that will allow her to further detail her use. To ask, "Does your husband know you are using these alternative medications?" (choice A) is inappropriate. The physician's role is to care for the patient. Whether the patient reveals her use of alternative medicines to her husband is not the prime concern to the physician. This question is more likely to create conflict than reveal needed information for the physician. To ask, "Do you realize how dangerous alternative medicines are?" (choice B) is incorrect. This question is confrontational and judgmental. Many alternative therapies are safe and effective. To ask, "Why don't you stick with traditional medicines?" (choice D) is inappropriate. If a patient has a condition and there is a remedy from the conventional medical system (known as allopathy in North America) available, then it is reasonable to offer this remedy as a possibility for the patient. However, inquiring as to why the patient doesn't "stick" with traditional medicine is likely to cause confrontation and a worsening of the patient-doctor relationship. To ask, "Why haven't you revealed your use of alternative medications before?" (choice E) is also somewhat challenging and confrontational. Perhaps the patient did not think a conventional physician would be accepting of CAM. The important step at this point is to identify the medications and discuss their risks, benefits, and side effects with the patient, as one would with traditional medications. A 35-year-old woman, gravida 3, para 2, at 39 weeks' gestation, comes to the labor and delivery ward with contractions. Past obstetric history is significant for two normal spontaneous vaginal deliveries at term. Examination shows the cervix to be 4 centimeters dilated and 50% effaced. The patient is contracting every 4 minutes. Over the next 2 hours the patient progresses to 5 centimeters dilation. An epidural is placed. Artificial rupture of membranes is performed, demonstrating copious clear fluid. 2 hours later the patient is still at 5 centimeters dilation and the contractions have spaced out to every 10 minutes. Which of the following is the most appropriate next step in management? A. Expectant management B. Intravenous oxytocin C. Cesarean delivery D. Forceps-assisted vaginal delivery E. Vacuum-assisted vaginal delivery Explanation: The correct answer is B. This patient is demonstrating an abnormal labor pattern with arrest of dilation. The normal pattern of labor is one of continued progression. Whether a patient is in the latent phase or the active phase, there should be a gradual progression with an increase in the amount of cervical dilation. This patient, however, has stopped dilating and has had her contractions space out considerably. An arrest of labor like this can be caused by several reasons: contractions may not be adequate; the fetus may have a malpresentation; or the maternal pelvis may not be able to accommodate the fetus. In this case it appears that the contractions are not adequate, so at this point, it would be reasonable to give intravenous oxytocin in an effort to re-establish a contraction pattern that can effect a vaginal delivery. Expectant management (choice A) would not be the most appropriate next step. The patient is clearly demonstrating a dysfunctional labor pattern at this point. To "watch and wait" in the face of insufficient uterine contractions is to place the patient at risk of an even longer labor and the correspondingly higher risk of infection. Cesarean delivery (choice C) would not be the most appropriate next step in management. This patient may very well need a cesarean delivery if she is truly unable to progress in labor. However, it is worth attempting a vaginal delivery in this multiparous patient who has already had two vaginal deliveries. To attempt a forceps-assisted vaginal delivery (choice D) or a vacuum-assisted vaginal delivery (choice E) would be contraindicated. This patient's cervix is only 5 centimeters dilated. Forceps and vacuum cannot be attempted in patients unless they are fully dilated and at +2 station or lower. A 22-year-old woman comes to the physician for an annual examination. She has been sexually active since the age of 15 and has not had regular Pap smears or examinations. She is currently sexually active with multiple partners and intermittently uses condoms. She has no medical problems and takes no medications. Her examination is unremarkable. Her Pap smear is described as satisfactory but limited by the absence of endocervical cells. It is otherwise within normal limits. Which of the following is the most appropriate next step in management? A. Repeat the Pap smear in 1 year B. Repeat the endocervical portion of the Pap test as soon as possible C. Perform colposcopy with colposcopically directed biopsies D. Perform laparoscopy with laparoscopically directed biopsies E. Perform exploratory laparotomy Explanation: The correct answer is B. A Papanicolaou smear should ideally be a sampling of the transformation zone. An adequate sample should show endocervical cells. When endocervical cells are not present, there is some question as to whether the transformation zone was fully sampled. If a woman has no risk factors for cervical dysplasia, has had three normal annual Pap smears in a row, and has a current Pap that shows no abnormality other than the absence of endocervical cells, then the Pap smear can be repeated in 1 year. This patient, however, has significant risk factors for cervical dysplasia, including early initiation of sexual activity, multiple partners, and unprotected intercourse. Therefore, this patient needs the endocervical portion of the Pap test to be repeated as soon as possible. To repeat the Pap smear in 1 year (choice A) would be incorrect management. As noted above, repeating the Pap smear in 1 year is correct only in patients who have no risk factors for cervical dysplasia, three normal annual Pap smears, and a present Pap that is normal except for the lack of endocervical cells. To perform a colposcopy with colposcopically directed biopsies (choice C) would not be correct. This patient has a normal Pap smear overall. The lack of endocervical cells makes the smear incomplete but not abnormal. To perform laparoscopy with laparoscopically directed biopsies (choice D) would not be correct. Laparoscopy does not allow evaluation of the cervix and is not indicated for abnormal or incomplete Pap smears. To perform an exploratory laparotomy (choice E) is not indicated. Again, this patient has a normal but incomplete Pap smear, and major surgery would not be correct management. A 23-year-old primigravid woman at 29-weeks' gestation comes to the physician because of contractions. She states that they have been occurring every 3-5 minutes for the past few hours and that they are worsening in intensity. Examination reveals that the patient is afebrile and her abdomen is nontender. Her cervix is 3 cm dilated, and the fetus is in vertex position. The patient is started on IV magnesium sulfate and penicillin and given an intramuscular injection of betamethasone. Which of the following represents the most significant consequence of this patient's preterm labor? A. Cesarean delivery B. Forceps assisted vaginal delivery C. Maternal infection D. Neonatal prematurity E. Shoulder dystocia Explanation: The correct answer is D. Preterm labor is a major problem in the U.S. Estimates are that it affects somewhere between 5% and 10% of all pregnancies. The exact etiology of the preterm labor is usually difficult to determine. Theories abound as to why some women develop contractions and cervical dilation prior to term whereas others do not. Possible etiologies include infection, dehydration, cervical weakness, multiple gestation, and uterine anomalies. The most significant consequence of preterm labor is that it often results in premature delivery of a premature neonate. Premature neonates are at high risk for pulmonary immaturity, intraventricular hemorrhage, necrotizing enterocolitis, apnea, bradycardia, and other complications. Cesarean delivery (choice A) is not necessarily a consequence of preterm labor. This fetus is in the vertex position, and this patient, should she have unstoppable preterm labor, could have a vaginal delivery. Forceps assisted vaginal delivery (choice B) is not necessarily a consequence of preterm labor. If this patient is in unstoppable preterm labor, she may have a vaginal delivery without the need of forceps. Maternal infection (choice C) may be the cause of this patient's preterm labor, but it is unlikely to be the most significant consequence of the preterm labor. Shoulder dystocia (choice E) has been reported to occur even in a preterm delivery, although this is rare. The most significant consequence of preterm labor is neonatal prematurity, not shoulder dystocia. A 65-year-old woman comes to the physician because of bleeding from the vagina. She states that her last menstrual period was at age 50 and that she has had no bleeding since. She has no medical problems and takes no medications. She is not sexually active. Examination is unremarkable, including a normal pelvic examination. After informed consent is obtained, an endometrial biopsy is performed. The patient complains of discomfort during and after the procedure but feels well enough to go home. Later that night, with her abdominal pain worsening, the patient comes to the emergency department. An ultrasound is performed that shows a normal uterus and adnexae but a complex fluid collection posterior to the uterus. Which of the following is the most likely diagnosis? A. Bowel perforation B. Endometritis C. Endometrial cancer D. Tuboovarian abscess E. Uterine perforation Explanation: The correct answer is E. This patient presents with postmenopausal bleeding. The majority of patients who have postmenopausal bleeding will not have endometrial hyperplasia or cancer. However, because postmenopausal bleeding is the most common presenting complaint of women with endometrial cancer, it is important to rule this out. A common way to evaluate the endometrium is with an endometrial biopsy. This can be performed with a small suction cannula that is introduced through the cervical os and into the uterine cavity to get a sample of the endometrium. The procedure is standard in the practice of gynecology but is not without risks. One of the risks of endometrial biopsy is uterine perforation (i.e. advancing the cannula too far such that it penetrates and perforates through the wall of the uterus). This patient has evidence of uterine perforation. First, she experienced significant pain during the procedure and continuing afterwards. While endometrial biopsy can cause considerable discomfort, it is usually of a crampy nature that should resolve shortly after the procedure. Second, her pelvic ultrasound now shows a complex fluid collection posterior to the uterus, which likely represents a collection of blood in the posterior cul-de-sac. If the patient has stable vital signs and an acceptable hematocrit, uterine perforation can be managed expectantly. If, however, the patient has evidence of hemodynamically significant bleeding, then she will require operative intervention. Bowel perforation (choice A) is a very unlikely complication with an endometrial biopsy. It's rare for the cannula to be advanced far enough to damage the uterus (uterine perforation), let alone damage the bowel. Endometritis (choice B) can be a complication of an endometrial biopsy. Patients undergoing endometrial biopsy should be counseled that infection is one of the risks of the procedure. However, this patient is afebrile and the pelvic fluid collection is more suggestive of a perforation than an endometritis. While it is possible that this patient has endometrial cancer (choice C), it is not likely that endometrial cancer is causing her acute problem. Again, most women with postmenopausal bleeding do not have endometrial cancer. And, this patient's sudden onset of pain and pelvic fluid collection after endometrial biopsy is most suggestive of endometrial cancer. A patient with a tuboovarian abscess (choice D) usually presents with abdominal pain and fevers, and ultrasound will reveal a pelvic mass. In a non-sexually active patient with no adnexal mass, tuboovarian abscess can be effectively ruled out. A 22-year-old woman, gravida 2, para 0, at 8 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her first pregnancy resulted in a 22-week loss when she presented to her physician with bleeding from the vagina, was found to be fully dilated, and delivered the fetus. Examination of the patient today is unremarkable. She declines to have a cerclage placed. When should this patient begin having regular cervical examinations? A. 10 weeks B. 16 weeks C. 22 weeks D. 28 weeks E. 37 weeks Explanation: The correct answer is B. This patient has an obstetrical history that is consistent with abnormal cervical competence. This diagnosis may be made when the patient has a history of painless cervical dilation in the second trimester. Cervical incompetence is a cause of second-trimester pregnancy loss and preterm delivery. Cervical incompetence may be congenital and/or acquired. Women who have had previous trauma to the cervix (e.g. dilation of the cervix, cervical conization, or obstetric trauma) and women with mullerian anomalies, or a history of in-utero exposure to diethylstilbestrol may be at increased risk. This patient, given her history, was offered a cerclage. Cerclage is a procedure in which a suture is placed at the level of the internal os after bladder dissection (Shirodkar) or as high up on the cervix as possible (McDonald). A prophylactic cerclage is placed between 12 and 16 weeks' gestation. Once the cerclage is placed, the patient should not engage in sexual intercourse, prolonged standing, or heavy lifting. This patient, however, refused to have a cerclage placed. Given her history, however, she needs to be followed closely to ensure that any signs of cervical incompetence are detected as soon as possible. Regular examinations of the cervix, either digitally or with ultrasound, should begin at 16 weeks because cervical incompetence becomes a concern during the second trimester. Starting regular examinations at 10 weeks (choice A) is unlikely to be helpful. Cervical incompetence most often manifests itself in the second or third trimester. Starting regular examinations at 22 weeks (choice C) or 28 weeks (choice D) would not be correct, as these gestational ages may be too late to detect cervical changes. This patient lost her last pregnancy at 22 weeks, which means that her cervix may have started changing several weeks earlier. To wait until 22 or 28 weeks would risk missing cervical changes and the possibility of instituting changes (e.g., bed rest, hospitalization, or cerclage placement) to help prevent pregnancy loss. 37 weeks (choice E) is the time at which a cerclage should be removed. In a woman with a history of a 22-week loss, waiting until 37 weeks to start checking the cervix regularly would not be appropriate.