Reproduction
When educating a patient about risks of undergoing surgical repair of a rectocele, which of the following potential complications should be mentioned? ADyspareunia BRectal fissure CRectus diastasis DSmall bowel obstruction
A A rectocele is a posterior vaginal wall defect associated with anterior prolapse of the rectum. It is a defect in the rectovaginal septum rather than the rectum. Patients typically complain that they feel increased pelvic pressure or the sensation that something is "falling out" of the vagina. In addition, patients often utilize splinting of the vagina, perineum or rectum in order to achieve a bowel movement. Splinting is the firm application of pressure on a particular anatomical location. Other symptoms include constipation, fecal incontinence or sexual dysfunction. Diagnosis can usually be made during vaginal and rectal examination by observing a bulge in the posterior vaginal area upon bearing down. Imaging is rarely needed. Nonsurgical management involves medications for constipation to minimize straining that may make the rectocele worse and pessary placement. Surgical repair with a posterior colporrhaphy has an anatomic cure rate of up to 96%. Dyspareunia is a potential complication that patients should be educated about when undergoing surgical repair of a rectocele.
The presence of which one of the following best differentiates a diagnosis of premenstrual dysphoric disorder from premenstrual syndrome? AAffective symptoms BConfusion and other cognitive changes CMood stability DSerotonin dysfunction
A According to the American Psychiatric Association DSM-5, mood swings, anger, irritability, a sense of hopelessness or tension, and anxiety or feeling on edge associated with severe PMS symptoms is defined as premenstrual dysphoric disorder. Affective symptoms may be common in PMS but at least one affective symptom is required for the diagnosis of PMDD.
A 41-year-old woman suffers from heavy and irregular menses, which at times leads to fatigue, lightheadedness, and dyspnea. She has had three hospitalizations in the past year for such episodes. Her gynecologic evaluation has not revealed any pathological cause. The heavy menses continue despite hormonal therapy. Which of the following treatment options should be considered next? AColposcopy BEndometrial ablation CHysterectomy DHysteroscopy
B Abnormal uterine bleeding (previously dysfunctional uterine bleeding) is diagnosed once pathologic causes of abnormal uterine bleeding have been excluded. Most of these patients are anovulatory, and although the exact cause is unclear, the underlying pathophysiology is felt to be due to abnormalities in the hypothalamic-pituitary-ovarian axis that result in unopposed estrogen production. Continued estrogen proliferation of the endometrium causes it to outgrow its vascular supply and slough irregularly, sometimes leading to serious acute or chronic hemorrhage. Baseline treatment includes estrogen, progesterone, or combination hormone therapy. If hormones do not control bleeding and symptomatic anemia continues, practitioners consider surgical measures to control persistent, symptomatic, irregular bleeding. Options include dilation and curettage or endometrial ablation, and if these fail, hysterectomy may be a last resort.
A 30-year-old woman who had an uncomplicated pregnancy delivered a healthy newborn a few minutes ago. She just now delivered a portion of the placenta with large areas absent of cotyledons. Copious amounts of blood begin to flow from the vaginal orifice. Within minutes, the patient becomes lightheaded but maintains consciousness. You attempt manual extraction but obtain minimal pieces of placental tissue. The bleeding continues, and the blood pressure decreases to 78/68 mm Hg while heart rate increases to 136 bpm. Which of the following is the best next step in management of postpartum hemorrhage? ABlood type and cross-match BTransfer to the operating room CUterine artery ligation DUterine packing with gauze
B Postpartum hemorrhage can be a serious, and sometimes fatal, situation. One of the causes is retention of placental tissue, which is usually due to abnormal placental implantation or an abnormal separation process. Delivery of an incomplete placenta, for example, one that is abnormally shaped or missing some of its normal septations (cotyledons), may prevent normal postpartum uterine contractions. This can lead to improper constriction of the spiral arteries (uterine atony), and ultimately, excessive bleeding. If retained placenta is a highly suspected cause of postpartum hemorrhage, immediate digital extraction should be performed by inserting fingers through the cervix and into the uterus, then using them to direct and maneuver any remaining intrauterine tissue out through the vagina. If this is unsuccessful and bleeding continues or the patient decompensates, curettage with a suction device or sharp curette is recommended, or if risk factors for placenta accreta exist, exploratory laparotomy. Adjuvant interventions include alerting anesthesia, type and cross-match of blood products, establishing double large-bore intravenous access, uterine massage, oxytocin, methylergonovine maleate, and possible code hemorrhage.
A 15-year-old girl complains of vaginal discharge over the past two weeks. She reports recently becoming sexually active but uses condoms consistently during intercourse. Which of the following favors a diagnosis of bacterial vaginosis over trichmoniasis? AImprovement on oral metronidazole BMultiple punctate hemorrhagic cervical lesions CPredominance of gram negative rods on gram stain DVaginal pH of 5.5
C
A 17-year-old girl is seen in clinic due to complaints of excessive body hair. She denies taking any medication. She has irregular menses and denies sexual activity. On exam, her BMI is 31, with moderate hirsutism on upper lip and chest, moderate acne on her face, Tanner 5 breasts and pubic hair. The rest of her exam findings are normal. Which of the following is an expected laboratory finding? AIncreased cortisol BIncreased follicle-stimulating hormone CIncreased luteinizing hormone DIncreased thyroid-stimulating hormone
C
A 22-year-old woman presents to your office with complaints of pelvic pain and vaginal discharge. She reports having recent unprotected intercourse with a new partner and her last menstrual period ended three days ago. Which of the following is the most appropriate pharmacologic treatment? AAzithromycin plus ceftriaxone BCeftriaxone plus azithromycin plus probenecid CCeftriaxone plus doxycycline plus metronidazole DMetronidazole
C
A 23-year-old nulligravida comes to your office for contraception counseling. She has a seizure disorder that is well controlled on carbamazepine. She is a nonsmoker and has no other medical problems or complaints. She is currently in a relationship and does not want to get pregnant in the next several years. Which one of the following contraceptives is the most appropriate? ACombined oral contraceptives BEtonogestrel/ethinyl estradiol vaginal ring CLevonorgestrel intrauterine device DProgestin-only pills
C
A 24-year-old G1P0 woman presents to the emergency department for atraumatic vaginal bleeding at 12 weeks of gestation. The woman's vital signs are within normal limits. On examination, she is found to have blood in the vaginal vault with an open cervical os. Obstetrics is consulted. Rh(D) immunoglobulin is given to the patient after laboratory results are available. Which of the following test results indicated the patient's need for Rh(D) immunoglobulin? ADecrease in hCG by 40% BLow hemoglobin and hematocrit on complete blood count CNegative Rh(D) on blood typing and antibody screen DPositive Kleihauer-Betke test
C
A 26-year-old woman presents with a monochorionic, diamniotic twin pregnancy at 20 weeks of gestation in which polyhydramnios is visualized on ultrasound in twin one, and oligohydramnios in twin two. Doppler flow from placenta to both fetuses is good. The bladder of twin two is not visualized. Which of the following clinical interventions would be the best choice for this patient? AAmnioreduction BExpectant management with weekly Doppler blood flow studies CFetoscopic laser ablation of placental anastomoses DSelective reduction
C
A 27-year-old woman is on an estrogen-progestin oral contraceptive. Which of the following mechanisms of action is the most important for providing contraception? AAlteration in cervical mucus BImpairment of normal tubal motility and peristalsis CInhibition of the midcycle luteinizing hormone surge DRendering the endometrium less suitable for implantation
C
A 29-year-old woman who is one week postpartum following a pregnancy complicated by preeclampsia with delivery of a full-term infant is brought in by emergency medical services with an ongoing generalized tonic-clonic seizure. Which of the following medications should be administered first? ALabetalol BLorazepam CMagnesium sulfate DPhenobarbital
C
A 30-year-old woman presents to the office with dysmenorrhea, pelvic pain, and infertility for the last 5 years. What is the most appropriate next step to confirm a diagnosis of endometriosis? ABloodwork BColposcopy CLaparoscopy DPelvic ultrasound
C
A 35-year-old G2P1 woman at 28 weeks gestation presents to the Emergency Department with abdominal pain, continuous uterine contractions, and decreased fetal movement. She has a history of hypertension and endorses a 1.5 pack per day smoking history. She denies any vaginal bleeding or rush of water. Her vital signs upon arrival are T 37.2°C, HR 130, BP 80/50, RR 22. Fibrinogen is 200 mg/dL. A fetal heart rate by bedside Doppler is 100. Physical exam reveals a rigid, tender uterus. An ultrasound shows a normally implanted posterior placenta with diffuse thickening. Which of the following is the most likely diagnosis? AChorioamnionitis BPlacenta accreta CPlacental abruption DUterine rupture
C
A 40-year-old woman with a history of asthma presents to the ED with symptoms of wheezing and shortness of breath similar to previous exacerbations. Her vital signs are BP 115/70 mm Hg, HR 80 bpm, RR 14/min, and pulse oximetry 99% on room air. The patient is offered and agrees to a point-of-care beta-hCG test that returns positive. Upon further questioning, patient denies any vaginal or urinary complaints. On exam, you note mild bilateral wheezing with good air movement. Which of the following is the most appropriate next step in management? ADelay treating her asthma until her pregnancy status is further clarified BTreat her asthma as indicated and perform a beta-hCG quantitative level CTreat her asthma as indicated and, if improved, discharge with outpatient obstetrical follow-up DTreat her asthma as indicated, perform a beta-hCG quantitative level, and obtain a pelvic ultrasound
C
A 52-year-old woman presents to the clinic complaining of hot flashes and difficulty sleeping through the night. She states her last menstrual period was over 12 months ago. Which of the following laboratory results would be expected? ADecreased luteinizing hormone BElevated anti-müllerian hormone CElevated follicle-stimulating hormone DElevated inhibin B
C
A 68-year-old postmenopausal woman presents to the outpatient gynecology office complaining of a single, pruritic plaque located on the left labia majora for two months. She denies vaginal or vulvar discharge, hematuria, abdominal pain, weight loss, nights sweats or fatigue. She denies any changes to her laundry detergent or body soaps. Her gynecologic history is significant for prior abnormal PAP smears secondary to human papillomavirus infection that was successfully treated with colposcopy. What is the most likely diagnosis? ACandidiasis BCondyloma accuminata CVulvar cancer DVulvar contact dermatitis
C
A G2P2 46-year-old woman presents to her gynecologist's office with a six month history of irregular, heavy menses. She states her cramps are no worse than usual and she does not have dyspareunia or postcoital bleeding. On physical exam, she has a body mass index of 32 kg/m2. A bimanual examination reveals a normal-appearing cervix and a smooth, regularly-shaped uterus that is not enlarged. Which of the following is the most likely diagnosis? AAdenomyosis BCervical polyps CEndometrial hyperplasia DUterine leiomyoma
C
A previously healthy 35-year-old woman presents to your clinic with questions about breast cancer screening. She has no family history of breast cancer and wants to know when she should start screening. Per the United States Preventive Services Task Force, which of the following is the most appropriate next step in management? AInitiate screening magnetic resonance imaging at age 40 BInitiate screening mammography at age 40 CInitiate screening mammography at age 50 DInitiate screening ultrasound at age 50
C
Which of the following is a risk factor for occiput posterior position at birth? AGestational age less than 38 weeks BMaternal age < 35 years CNulliparity DPosterior placenta
C
A 14-year-old girl has been diagnosed with primary amenorrhea. Pelvic ultrasound reveals an absent uterus. Genetic testing confirms a 46,XX karyotype. Which of the following is the most likely diagnosis? AAsherman syndrome BImperforate hymen CMüllerian dysgenesis DTurner syndrome
C Müllerian dysgenesis (normal complement of sex chromosomes: 46,XX) is a uterine abnormality in which there is a congenital absence of the uterus and vaginal upper two-thirds. Primary amenorrhea can be a result of several gynecologic anatomic abnormalities, as discussed below.
A 15-year-old girl presents with generalized abdominopelvic pain that occurs every month after her regular, nonpainful menses. The pain, which is associated with headaches, bloating, and depressed mood, begins 18 days after the last day of menstruation. She also complains of cyclic ankle swelling but denies a history of increased salt intake. Which of the following is the most likely diagnosis? AAmenorrhea BDysmenorrhea CPremenstrual dysphoric disorder DPremenstrual syndrome
D
A 22-year-old woman presents with vaginal bleeding with clots that started one hour prior to arrival. She is 10 weeks pregnant based on a previous ultrasound confirming her intrauterine pregnancy. Bedside ultrasound today does not show an intrauterine pregnancy. Her blood type is A negative and the father of the baby's blood type is not currently known. Which of the following is the best strategy for administration of Rh immunoglobulin? AA test dose should be administered first because of the risk of an anaphylactoid reaction BRh immunoglobulin 300 µg is required CRh immunoglobulin is not indicated DShe should receive Rh immunoglobulin 50 µg within 72 hours
D
A 22-year-old woman with regular menstrual cycles presents with symptoms concordant with premenstrual syndrome. In evaluating the large differential of these symptoms, which one of the following serum laboratory tests is recommended? AEstrogen BFollicle-stimulating hormone CHuman chorionic gonadotropin DThyroid-stimulating hormone
D
A 23-year-old woman presents with concerns of tender breast enlargement. She gave birth to a healthy newborn 2 weeks ago, and she currently breastfeeds. Examination reveals subjective fevers, myalgias, and general erythema, warmth, and edema of the right breast. There is mild overlying erythema, but no other superficial abnormalities, palpable masses, or purulent nipple discharge present. The left breast appears normal. Which of the following is the most likely diagnosis? ABreast abscess BBreast engorgement CInflammatory breast cancer DLactation mastitis
D
A 24-year-old woman comes to the clinic complaining of lower abdominal and pelvic pain. She says the pain has been ongoing for 3 to 4 weeks and is exacerbated when she has sexual intercourse with her boyfriend. She has had four sexual partners in the past year and only uses oral contraceptive pills for birth control. She also has dysuria and dysmenorrhea. Physical examination shows diffuse tenderness in the lower abdominal quadrants and cervical discharge. Which of the following is the most likely diagnosis? AEctopic pregnancy BEndometriosis CHuman papillomavirus DPelvic inflammatory disease
D
A 24-year-old woman presents for an initial evaluation of cyclical symptoms of irritability, painful bloating, and depression. These symptoms occur regularly 4-5 days prior to the beginning of menstruation. During these few days, the patient typically has to miss work due to the "awful pain and mental clouding." Which one of the following treatment options do you recommend as first-line therapy? AAnticholinergics BHysterectomy COral contraceptive pills DSelective serotonin reuptake inhibitors
D
A 25-year-old G2P1 woman presents to your office at 32 weeks gestation with a complaint of severe itching, particularly on the palms of her hands and the soles of her feet. Lab results reveal elevated bile acids. Regarding this disease, which of the following statements is most correct? AAminotransferases are low BDisease recurrence is rare in subsequent pregnancies CThe treatment of choice is cholestyramine DThere is an increased risk for fetal demise
D
A 26-year-old obese woman with a 2-year history of increased acne, abnormal hair growth, and menstrual abnormalities presents to her obstetrician for an infertility workup. A pelvic ultrasound reveals enlarged cystic ovaries. She desires to become pregnant. Which of the following is the next best step in treatment? AClomiphene citrate BGonadotropin therapy CSpironolactone DWeight reduction
D
A 28-year-old woman at 31 weeks gestation comes to the emergency department after noticing a gush of clear fluid from her vagina. Which of the following features is most suggestive of prelabor rupture of membranes? AMicroscopic evaluation of vaginal fluid revealing pseudohyphae BPresence of bloody vaginal secretions CVaginal epithelial cells with a stippled appearance on microscopic evaluation DVaginal fluid pH > 6.5
D
A 31-year-old woman at 35-weeks gestation presents with brief painless, bright red vaginal bleeding. In addition to fetal monitoring, which of the following is the most important initial management? AAdministration of betamethasone to hasten fetal lung maturity BSterile digital cervical exam CSterile speculum examination DTransvaginal ultrasound
D
A 35-year-old obese woman who just delivered a 10 lb baby after 48 hours of labor starts hemorrhaging from the vaginal area and has a sudden drop in blood pressure. She was in her 41st week of gestation when she was admitted to have labor induced. Which of the following is the best initial step in diagnosing the underlying cause of bleeding? ADo manual exploration of the uterine cavity BOrder a complete blood count COrder a pelvic and abdominal ultrasound to identify the source of bleeding DPalpate to determine the size and firmness of the uterus
D
A 58-year old postmenopausal woman presents with painless vaginal bleeding. Her last menses occurred 5 years ago. She reports that her Papanicolaou smears have always been normal; the last one was obtained a year ago. Which of the following is the next step in management? AColposcopy with endocervical curettage BHysteroscopy CRepeat Papanicolaou smear DTransvaginal ultrasound
D
A 65-year-old patient is diagnosed with stage III endometrial adenocarcinoma. You decide to refer her to a gynecologic oncologist. She asks you to explain the "best treatment available." In your counseling, you discuss which one of the following treatment options? AChemotherapy BExternal beam radiation CPartial vaginal hysterectomy DTotal abdominal hysterectomy
D
A postmenopausal woman presents with abnormal vaginal bleeding. You suspect endometrial malignancy and refer the patient for further investigation. Which of the following modalities is initially used to determine a diagnosis? AColposcopy BDilation and curettage CPapanicolaou test DPipelle endometrial suction curette
D
Which of the following is the most appropriate treatment for stage IV uterine prolapse in a 50-year-old woman with no medical problems and no previous surgical history? AAbdominal hysterectomy BAnterior colporrhaphy CPosterior colporrhaphy DVaginal hysterectomy
D
Which of the following laboratory studies should be performed on all pregnant women during the initial prenatal visit? AHepatitis C antibodies BThyroid stimulating hormone CTuberculin skin testing DUrine culture
D
A 29-year-old woman presents with cyclic pelvic pain that has been increasing over the last 7 months. She complains of significant dysmenorrhea, heavy menstrual bleeding, and dyspareunia. She uses condoms for birth control. On physical examination her uterus is retroverted and non-mobile, and she has a palpable adnexal mass on the left side. Her serum pregnancy test is negative. Which of the following is the most likely diagnosis? AEndometriosis BFunctional ovarian cyst COvarian cancer DPelvic inflammatory disease
A
A 38-year old woman presents with right upper quadrant pain that is worse with deep breathing. She reports having multiple sexual partners. She was recently treated for "an STD," however, she didn't complete the entire course of antibiotics because "she felt fine." What is the most likely organism causing this condition? AChlamydia trachomatis BEscherichia coli CTreponema pallidum DTrichomonas vaginali
A
A 41-year-old G3P1011 woman, who is 12 weeks pregnant, presents to the ED with a chief complaint of vaginal bleeding with passage of clots. She also complains of one week of back and pelvic pain and cramping for which she is taking ibuprofen. A pelvic exam demonstrates an open cervical os. Transvaginal ultrasound reveals particles of conception within the cervical canal. Which of the following is the most likely diagnosis? AIncomplete abortion BInevitable abortion CMissed abortion DThreatened abortion
A
A 44-year-old woman with a history of hypertension presents to her primary care provider's office with complaints of nausea and vomiting. Her last menstrual cycle was six weeks ago. Two years ago she had a bilateral tubal ligation performed. On physical exam, her abdomen is nontender and her uterus is not enlarged. Pelvic exam is unremarkable. Her serum human chorionic gonadotropin level is 5,000 mIU/mL. A transvaginal ultrasound does not demonstrate an intrauterine gestational sac. Which of the following is the most likely diagnosis? AEctopic pregnancy BGestational trophoblastic disease CHeterotopic pregnancy DThreatened abortion
A
A woman presents with fever and foul-smelling vaginal discharge three days after delivery of a full-term fetus. She is febrile, with uterine tenderness on pelvic exam. Which of the following is the strongest risk factor for postpartum endometritis? ACesarean section BInternal fetal monitoring CMultiple gestation DPrelabor rupture of membranes
A
According to the United States Preventive Services Task Force (USPSTF), which of the following is considered to put a pregnant woman at high risk for developing preeclampsia? AAutoimmune disease BHistory of cesarean section CHyperlipidemia DYoung maternal age
A
What is the most common presenting symptom in a woman with vaginal cancer? AVaginal bleeding BVaginal discharge CVaginal mass DVaginal pruritus
A
Which of the following contributes to a higher Bishop score? AAnterior cervical position BCervical effacement of 0 to 30% CFetal station of -3 DFirm cervical consistency
A
Which of the following correctly describes physiologic changes that occur in pregnancy? ABlood volume increases BFunctional residual capacity increases CGastrointestinal motility increases DHemoglobin concentration increases
A
A 14-year-old otherwise healthy boy presents to your clinic with his father. He is concerned because his breasts are enlarged. Appropriate management includes which of the following? ABRCA gene testing BReassurance CSerum estrogen level DUltrasound
B
A 21-year-old woman presents with pelvic pain that has been worsening over the last two days. She reports vaginal discharge, nausea, and chills for the last week. Physical exam reveals thin, copious vaginal discharge, cervical motion tenderness, and a mass in the left adnexa. Pregnancy test is negative. A pelvic ultrasound reveals a complex multiloculated left adnexal mass. Which of the following antibiotic regimens represents the most appropriate pharmacotherapy? AAmpicillin/sulbactam and clindamycin BCefoxitin and doxycycline CCeftriaxone and azithromycin DVancomycin
B
A 24-year-old woman presents for follow-up after an abnormal Pap smear. Colposcopy is performed and reveals a white, sharply demarcated area on the cervix after application of acetic acid. What is the most likely diagnosis? ACarcinoma in situ BCervical dysplasia CInvasive carcinoma DNabothian cyst
B
A 27-year-old pregnant woman at 16 weeks gestation presents with vaginal discomfort and discharge. Nucleic acid amplification is consistent with trichomonas. Gonorrhea and chlamydia testing is negative. What is the best treatment regimen?' AAdminister intramuscular ceftriaxone and oral azithromycin in single doses BAdminister oral metronidazole 500 mg twice daily for 7 days CPrescribe intravaginal metronidazole for 5 days DRecommend watchful waiting and follow up with obstetrics
B
A 32-year-old woman presents to your office for a physical exam including a Papanicolaou test (Pap smear). Lab results reveal negative cytology and positive human papillomavirus (HPV). Which of the following is the most appropriate next step in management? ACounsel patient on safe sex practices BOrder colposcopyY CRepeat Pap smear and human papillomavirus testing in five years DRepeat Pap smear and human papillomavirus testing in one year
B
A 32-year-old woman presents with fever and lower abdominal pain. She has a history of pelvic inflammatory disease. Her vitals are T 38.4°C, HR 133 bpm, and BP 101/60 mm Hg. On examination, the patient is toxic appearing and has marked lower abdominal tenderness to palpation with rebound and guarding. Pelvic examination reveals cervical motion tenderness, scant discharge, and left adnexal tenderness. The patient's urine beta-hCG is negative. A transvaginal ultrasound is performed and reveals a complex cystic, thick-walled, well-defined mass in the left adnexa. Which of the following is the most appropriate next step in management? AAdminister ceftriaxone and discharge home with a 14-day course of doxycycline BBegin intravenous antibiotics and admit for possible drainage CObtain a CT scan to rule out appendicitis DSend a serum beta-hCG to rule out ectopic pregnancy
B
A 55-year-old woman presents to the oncology clinic to discuss therapy options for her newly diagnosed, non-metastatic, unilateral, invasive breast cancer. Routine analysis reveals estrogen receptor-positive and progesterone receptor-positive tumor expression. Which of the following is the recommended therapy for this patient? ACytotoxic chemotherapy alone BEndocrine therapy with breast surgery CMastectomy alone DRadiation therapy and radical mastectomy
B
A 58-year-old woman with no significant medical history presents for an annual wellness physical. She says it has been 16 months since she had any menstrual bleeding and notes moderate vaginal discomfort that makes coitus difficult for her. She has tried vaginal lubricants with minimal improvement. Which of the following recommendations would be most appropriate for this patient? AAvoidance of vaginal intercourse BPrescribe a vaginal ring containing estradiol CPrescribe an oral conjugated estrogen preparation DPrescribe gabapentin taken nightly
B
A male child born at 40 weeks of gestation has an Apgar score of 4 at birth. He is gasping for air and has a pulse of 68 despite positioning and airway clearance. Which of the following would be the best choice for initial clinical intervention in this patient? AIntubation BPositive pressure ventilation CSupplemental oxygen by facemask DWarming, drying, and close observation
B
Which U.S. Food and Drug Administration pregnancy category is defined by the following: Animal reproduction studies have failed to demonstrate a risk to the fetus, and there are no adequate and well-controlled studies in pregnant women. ACategory A BCategory B CCategory C DCategory D
B
Which of the following can help reduce the risk of developing lactational mastitis? AInfrequent feedings BLubricating ointment for excoriations and cracking CRapid weaning DWearing a tight brassiere
B
Which of the following represents a risk factor for developing vulvar cancer? AAlcohol abuse BCigarette smoking CObesity DSedentary lifestyle
B
A 26-year-old woman just vaginally delivered twin, macrosomic boys. This was her fourth pregnancy, which has been the longest of them all at 43 weeks gestation. Her delivery was difficult and required forceps to complete. Estimated blood loss was 1,100 mL. Currently, she is hypotensive, tachycardic, and anemic. Which of the following is the most likely diagnosis? AAmniotic fluid embolism BIncision dehiscence CRh sensitization DUterine atony
D Postpartum hemorrhage, excessive bleeding after delivery, is defined as blood loss > 1000 mL. It can be fatal to the mother. The most common cause is uterine atony. Normally after delivery, the uterus will contract, compressing the spiral arteries and placental bed, thus, preventing hemorrhage. Atony occurs when the normal contraction does not occur. Risk factors for atony are numerous and include general anesthesia, macrosomia, twins or prolonged pregnancy, multiparity, hydramnios, amnionitis, and prolonged or difficult labor. An atonic uterus feels soft and boggy. Treatment includes uterine massage and intramuscular methylergonovine maleate or oxytocin but may require surgical management (artery ligation, artery embolization, hysterectomy). Other causes of postpartum hemorrhage include lower genital tract lacerations or hematomas, retained placenta, uterine inversion, and maternal coagulopathy.
A 39-year-old woman in her third trimester presents with 2 days of bloody "spotting" on her underwear. This is her third pregnancy, which thus far has been uncomplicated. Her initial delivery was vaginal, and her second delivery was via cesarean section. She is currently sexually active and has a history of trichomoniasis. She denies pelvic pain. Laboratory examination reveals hematocrit of 32%, white blood cell count of 10,000/µL, platelet count of 260,000/µL, international normalized ratio of 1.1, and activated partial thromboplastin time of 32 seconds. Pelvic examination shows a nonerythematous cervix with clear mucus. Which of the following is the most likely diagnosis? ACervicitis BHemolysis, elevated liver enzymes, and low platelet count syndrome CMaternal coagulopathy DPlacenta previa
d
A 21-year-old woman with no prenatal care presents for evaluation of lower abdominal pain and fever. She estimates that she is approximately 7.5 months pregnant. On questioning, she acknowledges intermittent pain for two days and a gush of fluid shortly after the pain began. Her temperature is 101.8°F. Physical examination is notable for purulent material in the vaginal vault. Which of the following is the most likely diagnosis? AChorioamnionitis BEndometritis CPelvic inflammatory disease DUrinary tract infection
A
A 25-year-old G1P0 woman at 33 weeks gestation presents to her obstetrician with a complaint of wetness and leakage from her vaginal area. On physical exam, fluid can be seen coming from the cervical canal. The cervix is not dilated. Fern test is positive. Which of the following medications should be given at this time to delay delivery? AAmpicillin BBetamethasone CIndomethacin DProgesterone
A
A 25-year-old woman presents to her obstetrician for evaluation of recurrent second trimester pregnancy loss. During each of her previous two pregnancies, she presented during week 15 with painless cervical dilation and effacement with subsequent rapid delivery of a preterm infant. Which of the following is a risk factor for this woman's cervical insufficiency? AEhlers-Danlos syndrome BHistory of pelvic inflammatory disease CHuman papillomavirus infection DObesity
A
A 25-year-old woman presents to your clinic with concerns about sexually transmitted infections. She states she has unprotected sex with multiple partners. She is asymptomatic, but her last partner told her that he recently tested positive for chlamydia. Her urine pregnancy test is positive. The most appropriate next step is administration of which of the following? AAzithromycin BDoxycycline CMetronidazole DPenicillin
A
A 26-year-old previously healthy woman presents to the emergency department with abdominal pain. She was at home when she developed sudden onset lower abdominal pain followed by a brief syncopal episode. Her vital signs include blood pressure of 88/46 mm Hg, heart rate of 112 beats/minute, respiratory rate of 18 breaths/minute, temperature of 37.6°C, and oxygen saturation of 98%. She had a positive home pregnancy test yesterday. After initiating aggressive resuscitation, what is the most appropriate next step in management? AEmergent OB/Gyn consult BObtain a complete blood count CObtain a serum human chorionic gonadotropin (hCG) level DPelvic ultrasound
A
A 28-year old woman presents with several painful ulcers she has developed in the vaginal area. Examination reveals multiple 0.5 cm to 1.5 cm oval ulcers with sharply defined borders and a yellowish-white membrane. She denies recent sexual activity. Except for recurring aphthous ulcers of her mouth, her past history is unremarkable. Which of the following is the most likely diagnosis? ABehçet syndrome BHerpes simplex CReactive arthritis DSyphilis
A
A 32-year-old G4P3 woman with a history significant for polyhydramnios is brought to the emergency department 15 minutes after a home birth. She complains of persistent vaginal bleeding with thick clots. She is anxious and diaphoretic. Her physical exam is notable for a large, boggy uterus. She receives oxytocin intramuscularly as intravenous access is started. Repeat examination reveals a persistently boggy uterus with significant active vaginal bleeding. Which of the following is an absolute contraindication to the use of carboprost in the management of this patient? AAsthma BCoronary artery disease CHypertension DSeizures
A Postpartum hemorrhage is an obstetrical emergency and is the most common cause of maternal death globally. Postpartum hemorrhage is defined as a cumulative blood loss of greater than 1000 mL or bleeding that causes signs or symptoms of hypovolemia within 24 hours despite the delivery route. Management of postpartum hemorrhage should begin with identification of the cause of hemorrhage. The most common cause of postpartum hemorrhage is uterine atony. Other causes include retained products, genital tract lacerations, or, more rarely, maternal bleeding diathesis. First line treatment of uterine atony is manual uterine massage and uterotonic agents. Oxytocin is typically the first agent used, with carboprost and methylergonovine typically used in cases of continued bleeding after oxytocin use. Carboprost, a prostaglandin analog that stimulates uterine contractility, may cause significant bronchospasm and is contraindicated in patients with asthma.
Which of the following is considered appropriate treatment for bacterial vaginosis? A2% clindamycin cream intravaginally for 7 days BAzithromycin 1 g PO once CCeftriaxone 500 mg IM once DMetronidazole 2 g PO once
A The Centers for Disease Control and Prevention (CDC) recommends the following treatment regimens: metronidazole 500 mg PO bid for 7 days, 0.75% metronidazole gel 5 g intravaginally daily for 5 days, or 2% clindamycin cream 5 g intravaginally at bedtime for 7 days. For patients who cannot tolerate metronidazole, clindamycin 300 mg PO bid for 7 days is an alternative.
In the clinic, you are evaluating a 15-year-old girl who is complaining of increased vaginal discharge. She had her menarche at 12 years of age and since then has had irregular periods. She uses tampons during her menses. She notes thick yellowish vaginal discharge in between her periods. She denies burning, pain, or pruritus. She started to be sexually active for the past month with one partner. She uses condoms for contraception. On examination, you note Tanner 5 pubic hair and white discharge. You examine the discharge and obtain pH of 4, with negative whiff test and absence of clue cells on microscopy. You perform a pregnancy test, which is negative. Which of the following is the next best step? AAdvise her to stop using tampons BEncourage her to douche after her period CProvide her with reassurance DSend culture for Gardnerella vaginalis
C The girl's vaginal discharge is physiologic leukorrhea and therefore she should be reassured that this is normal. Normal vaginal discharge is composed of 1 to 4 ml fluid per day that is white or transparent, thick or thin, and usually odorless. The pH of normal vaginal secretions is 4.0 to 4.5. This is formed by mucoid endocervical secretions in combination with sloughing of epithelial cells and normal vaginal flora. The discharge may become more noticeable during the middle of menstrual cycle, during pregnancy, or with the use of estrogen-progestin contraceptives. The normal discharge may be yellowish, slightly malodorous, accompanied by mild irritative symptoms, but it is not accompanied by pruritus, pain, burning, erythema, or local erosion. The absence of these signs and symptoms distinguishes it from pathologic discharge like vaginitis or cervicitis.
An 18-year-old G1P0 woman at 16 weeks gestation presents with vaginal bleeding. She has had no prenatal care. Vital signs are unremarkable and physical examination only reveals a small amount of blood in the vaginal vault. A transvaginal ultrasound is performed as seen above. What is the next best step in management of this patient? AAdminister methotrexate BCT scan of the abdomen and pelvis CIntravenous antibiotics DObstetrics consultation
D This patient presents with vaginal bleeding and an ultrasound consistent with a hydatidiform mole or molar pregnancy requiring obstetrics consultation. Molar pregnancy is a spectrum of diseases characterized by abnormal chorionic villi proliferation. A complete hydatidiform mole refers to the situation in which there is no fetal tissue. In an incomplete mole, there is some fetal tissue along with trophoblastic hyperplasia. Patients with molar pregnancy may present with nausea, vomiting, abdominal pain, and vaginal bleeding. Without ultrasound, it is difficult to differentiate these patients from a threatened miscarriage or ectopic pregnancy. Often, the uterine size is larger than the expected for dates in molar pregnancy and the beta-hCG is higher than expected for dates. Diagnosis is based on characteristic findings on ultrasound. Hydropic vessels within the uterus cause a "snowstorm" appearance. Because of the potential for complications and the non-viability of the pregnancy, dilation and curettage is recommended. Once a hydatidiform mole is diagnosed, a chest X-ray should be obtained as trophoblastic tumors metastasize to lung, liver, and brain.
