women EOR part 1
three types of iuds dosges vs copper iud Which diagnostic tests are recommended immediately prior to inserting an intrauterine device?
13.5 mg levonorgestrel-releasing intrauterine device (A) that is effective for up to 3 years. It is the smallest intrauterine device available (along with the 19.5 mg device) and has a smaller-diameter inserter. This makes it an available option for nulliparous women. Since it has a lower dosage of levonorgestrel, most patients will continue to have menstrual bleeding with this device. 19.5 mg levonorgestrel-releasing intrauterine device (B) effective for up to 5 years. Patients report lighter menses but rarely amenorrhea 52 mg levonorgestrel-releasing intrauterine device for heavy bleader The copper intrauterine device (D) is a nonmedicated, 32 x 36 mm T-shaped copper device effective for up to 10 years. It works as a contraceptive by disrupting sperm motility, preventing egg fertilization, and inhibiting fertilized egg implantation. Unlike the other intrauterine devices, menses may be heavier and longer with this device. It is the only device appropriate for emergency contraception. Which diagnostic tests are recommended immediately prior to inserting an intrauterine device? Answer: Pregnancy testing and gonorrhea and chlamydia testing.
When is the best time to draw maternal serum alpha fetoprotein?
15-18 weeks
At which of the following gestational ages is this patient most likely to start feeling fetal movements?
19 weeks
A 26-year-old G3P1102 pregnant woman presents to the obstetric clinic for a routine prenatal visit. Physical examination reveals a uterine fundal height near the umbilicus. Which of the following gestational ages is most consistent with this fundal height, assuming a normal pregnancy? What factors reduce the diagnostic accuracy of physical exam-based gestational age assessment?
20 weeks 12 wk= pubic symphis 36 weeks = xyphoid 37- 40 regression What factors reduce the diagnostic accuracy of physical exam-based gestational age assessment? Answer: Leiomyoma, obesity, and pregnancies of multiple gestation.
how many weeks gestation can the yolk sac typically be visualized?
5 weeks What is Naegele rule? Answer: A calculation to estimate the date of delivery: first day of the last menstrual period + 7 days − 3 months + 1 year.
A 28-year-old G3P2002 woman presents to labor and delivery at 33 weeks and 1 day gestational age complaining of high home blood pressure readings. She reports no headache or visual changes. Her serial blood pressures 4 hours apart are 165/115 mm Hg and 173/102 mm Hg. Her urine dipstick shows 3 protein. Laboratory tests reveal a creatinine of 0.9 mg/dL and a platelet count of 160,000/µL of blood. Which of the following is the best management? What is the first sign of hypermagnesemia in patients being treated with magnesium sulfate to prevent seizures?What is the treatment of magnesium sulfate toxicity? When can magnesium sulfate be discontinued?
Administration of betamethasone and intravenous labetalol and admission for vaginal delivery She has preeclampsia with severe features dx preclampsia but the timing of delivery depends on the gestational age, severity of preeclampsia, and maternal and fetal condition Labetalol is one of the first-line antihypertensives. Preeclampsia is not an indication for a cesarean deliveryregardless of the presence of severe features. Antenatal corticosteroids are recommended for women diagnosed with preeclampsia if the gestational age is < 34 weeks. Betamethasone is the drug of choice. Intrapartum and postpartum seizure prophylaxis are recommended in all women with preeclampsia. Magnesium sulfate is the drug of choice What is the first sign of hypermagnesemia in patients being treated with magnesium sulfate to prevent seizures? Answer: Loss of the patellar reflex.. What is the treatment of magnesium sulfate toxicity? Calcium gluconate When can magnesium sulfate be discontinued? Answer: At least 24 hours after delivery.
A 28-year-old otherwise healthy pregnant woman presents to the emergency department at 20 weeks gestation with right flank pain. Her other symptoms include dysuria and chills. Vital signs are T of 101.6°F, HR of 114 bpm, BP of 120/80 mm Hg, RR of 20/min, and oxygen saturation of 98% on room air. Physical exam findings include right-sided costovertebral angle tenderness. Urinalysis shows pyuria and bacteriuria. Which of the following is the recommended management?
Admission and initiation of intravenous ceftriaxone dx= Acute pyelonephritis fever, flank pain, nausea, vomiting, and costovertebral angle tenderness Acute Pyelonephritis Sx: fever, dysuria, and flank pain PE: CVA tenderness Labs: UA + leukocyte esterase, nitrites, microscopy +WBCs, Gram stain, urine culture and susceptibility testing Most commonly caused by Escherichia coli Treatment depends on infection severity and community/host risk factors for resistant pathogens, options include fluoroquinolones, 3rd/4th gen cephalosporins, TMP-SMX. Critical illness or risk for multidrug resistant organisms: consider coverage for MRSA, VRE
A 35-year-old G2P1 woman at 16 weeks gestation presents to her obstetrician for a routine visit. Her medical history is significant for gestational diabetes and preeclampsia with her first pregnancy, chronic hypertension, and hypothyroidism. A quadruple test is ordered. Which of the following tests make up the quadruple test?
Alpha-fetoprotein, human chorionic gonadotropin, estriol, and inhibin A
A 32-year-old woman who is 37 weeks gestation presents to the maternity ward with a fever of 102.1°F and a heart rate of 115 bpm. She states that she has felt some leaking fluid from her vaginal area for the past 2 days but was unsure of what it was. A pelvic exam reveals fluid leakage from the cervical os. A fetal ultrasound reveals baseline fetal tachycardia. Which of the following antibiotic regimens is the treatment of choice for this patient?
Ampicillin and gentamicin dx :Intra-amniotic infection, also known as chorioamnionitis, infection or inflammation of the fetal amnion membrane and chorion membrane. caused by upward migration of vaginal flora to fetal membranes or by systemic spread. Patients may have a history of premature birth, premature labor, preterm premature rupture of membranes, prolonged rupture of membranes (> 18 hours), and history of colonization with group B Streptococcus (GBS) clinical dx maternal fever of > 100.4°F, maternal leukocytosis (> 15,000 cells/μL in the absence of corticosteroids), purulent fluid from the cervical os, and baseline fetal tachycardia. Other nonspecific signs, such as maternal tachycardia and uterine tenderness, may also be noted. Patients may also appear ill or toxic with hypotension, diaphoresis, and clammy skin. However, some patients may exhibit histologic intra-amniotic infection or silent intra-amniotic infection when maternal clinical signs and symptoms are absent Risk factors: nulliparity, prolonged rupture of membranes, meconium-stained amniotic fluid, internal fetal or uterine contraction monitoring Genital tract infection: STIs, group B Streptococcus, bacterial vaginosis Rx: ampicillin + gentamicin . Needle aspiration and analysis of the amniotic fluid can confirm the diagnosis of acute intra-amniotic infectio Treatment for both mother and neonate with chorioamnionitis includes antibiotic administration and expedited delivery. Initiating antibiotics during labor significantly reduces neonatal morbidity. Intravenous ampicillin and gentamicin is the standard antibiotic drug treatment, with clindamycin or metronidazole added for anaerobic pathogens in women undergoing cesarean delivery. When should antibiotics be discontinued in the mother? Answer: When she has been afebrile and asymptomatic for 24 hours.
A 24-year-old G2P1 woman at 32 weeks gestation presents to the ED with menstrual-like cramps, low back pain, vaginal pressure, and light vaginal bleeding. She reports no vaginal pain or drug use but smokes two packs of cigarettes each week. Uterine contractions are occurring 5 times every 20 minutes. Her vital signs are T 98.6°F, BP 136/84 mm Hg, HR 88 bpm, RR 20 breaths per minute, and pulse oximetry 98% on room air. Speculum examination reveals cervical dilation of 4 cm without any pooling of fluid into the posterior vaginal fornix. A fetal fibronectin test is positive. Her urinalysis is unremarkable. Fetal heart rate is 151 bpm, and the nonstress test is reactive. Rectovaginal swab for group B streptococcal testing is obtained. Which of the following clinical interventions is the most appropriate at this time?
Ampicillin, betamethasone, and magnesium sulfate look at image for management Preterm labor is defined by the presence of regular uterine contractions between 20-36 weeks gestation that results in cervical changes (e.g., effacement, dilation). (e.g., betamethasone) to enhance lung maturity, group B streptococcal infection prophylaxis (e.g., penicillin, ampicillin) until group B streptococcal testing comes back negative or the patient delivers, antibiotic treatment of any documented urinary tract or sexually transmitted infections, magnesium sulfate for neuroprotection (in patients 24-32 weeks gestation), and transfer to a better-equipped medical facility if necessary. Tocolytic drugs (e.g., indomethacin, nifedipine, magnesium sulfate, terbutaline) may be used to delay delivery for up to 48 hours to allow the antenatal corticosteroid to take full effect.
Which type of pelvis is characterized by convergent side walls of the pelvic midcavity, forward inclination of the sacrum, and a narrow subpubic arch of the pelvic outlet that will most likely lead to labor arrest?
Android "android phone has made its mid walls convergent moving forward in its sacred path making the outlet narrow " #most males have this type "plantinum is wide mid variety narrow inclined sacred use of it , straight force to the wide outlet" vs "frogs are narrow variety but wide include use , divergent forward movement " genicde is staright walled with wide forward march and outlet
Which of the following maternal characteristics is a risk factor for preterm labor?
Asthma an individual who has had one preterm birth is at increased risk for preterm labor in subsequent pregnancies. Pregnant patients with type 1 diabetes, hypertension, thyroid disease, asthma, kidney insufficiency, nonphysiologic anemia, major depressive disorder, and certain autoimmune disorders may be predisposed to preterm labor.
A 25-year-old woman presents to her gynecologist with irritability, anxiety, depressed mood, breast pain, bloating, and headaches. She states that her symptoms consistently begin at the same time during her menstrual cycle and last for 5 days before resolving. Which pattern of symptom onset best supports the suspected diagnosis?
At the end of the luteal phase
A 28-year-old otherwise healthy woman presents to the gynecology clinic with 24 hours of right-sided breast pain, redness, and swelling. She is 5 weeks postpartum. Vital signs are T of 100.6°F, HR of 98 bpm, BP of 120/80 mm Hg, RR of 20/min, and oxygen saturation of 98% on room air. Breast examination reveals a local area of erythema and firm edema on the right breast. Which of the following is the recommended treatment?
Continuation of breastfeeding and dicloxacillin dx:Lactational mastitis Continuation of breastfeeding and clindamycin (C) is incorrect because the patient does not have an indication for coverage for methicillin-resistant Staphylococcus aureus. Which antibiotic should be prescribed for periductal mastitis? Answer: Amoxicillin-Clavulanate. Mastitis Patient will be a breastfeeding mother Breast erythema, tenderness, fever Most commonly caused by Staph. aureus Management includes cool compresses and analgesics between feedings Antibiotics: dicloxacillin, cephalexin, TMP-SMX (MRSA), clindamycin (PCN allergy) Continue breast feeding to avoid progression to abscess
A 26-year-old G4P0121 woman presents to the emergency department at 15 weeks gestation with painless vaginal spotting. She reports she has had two miscarriages during the second trimester that presented similarly. Transvaginal ultrasound confirms cervical dilation and reveals a cervical length of 20 mm. Which of the following is the recommended treatment?
Cervical cerclage dx:Cervical insufficiency monitoring should be started at 14-16 weeks gestation. Women who develop a shortened cervix (< 25 mm) should be treated with a cervical cerclage. The diagnosis is often made based on obstetric history in women with at least two consecutive second-trimester pregnancy losses or extremely early preterm births (prior to 28 weeks) associated with minimal or mild symptoms. Exam findings that support cervical insufficiency are a dilated and effaced cervix in a woman without contractions or with minimal contractions inconsistent with the amount of cervical change. The diagnosis of cervical insufficiency is limited to singleton gestation
A 20-year-old nulliparous woman presents to the emergency department (ED) complaining of pelvic pain and fever and chills. Her symptoms have been going on for 3 days. She has had no new sexual partners, but does not routinely use condoms with her current partner because they "have been dating for 1 year." Clinically, her cervix is erythematous, friable, and there is a mucopurulent discharge. The cervical motion tenderness is significant. Her pregnancy test is negative and there are no adnexal masses. What is the MOST likely pathogen causing her symptoms?
Chlamydia trachomatis
A 47-year-old G3, P1 woman comes into the office complaining of heavy, painful, and irregular menstrual bleeding that has been going on for the past 6 months to a year. She has not been sexually active for the past year. On physical examination, her uterus is estimated to be the size of a uterus at 12 weeks' gestation. Pelvic ultrasound confirms the presence of a leiomyoma. Her hematocrit is 29%, mean corpuscular volume (MCV) is 68 fL, and serum ferritin is 10 g/L. What should be the first-line therapy?
Combined estrogen-progestin contraceptives (oral contraceptive pills, vaginal ring, or transdermal patch) are the most common medical therapy utilized by individuals with heavy menstrual bleeding and fibroids, especially those who desire contraception.
A 34-year-old woman is admitted in the hospital for routine care following a vaginal delivery. She plans on breastfeeding. You are counseling her on contraceptive options during the postpartum period. Which of the following contraceptive options is contraindicated during the postpartum period?
Combined hormonal contraceptives (pills, patch, or ring) are contraindicated for the first 6 weeks postpartum due to the increased risk of venous thromboembolism. AS ESTROGEN : will decrease lactaion / milk supply Progestin-only contraceptives can be used immediately following birth and do not interfere with breastfeeding. Barrier methods, abstinence, and withdrawal do not impact breast milk supply. <slynd (drosirenon) new drug that has 24 hr window vs 3hr and F/U in 3 months >
A 28-year-old woman with a past medical history of diabetes mellitus presents to the clinic with irregular menstrual cycles. She says her cycles occur every 2 months. Physical examination reveals male-pattern facial hair andinflammatory acne. Which of the following is the recommended treatment for her hyperandrogenic symptoms?
Combined oral contraceptive pill DX:Polycystic ovary syndrome (PCOS) insulin resistance and hyperandrogenism. Hyperandrogenism causes anovulation, which can lead to an accumulation of cysts within the ovaries. The classic features of PCOS include irregular menses (amenorrhea or oligomenorrhea) or abnormal uterine bleeding (related to ovulatory dysfunction), infertility, endometrial hyperplasia and increased risk of endometrial cancer, type 2 diabetes mellitus, and metabolic syndrome. Polycystic Ovary Syndrome (PCOS) Amenorrhea, obesity or overweight, hirsutism PE will show bilateral ovarian enlargement, acanthosis nigricans Labs will show high LH to FSH, androgen excess Most commonly caused by insulin resistance Treatment is combination oral contraceptive pills, lifestyle changes, metformin Most common cause of infertility What is the name of the criteria used to diagnose polycystic ovary syndrome? Answer: Rotterdam criteria.
A 25-year-old G1P0 woman at 28 weeks gestation presents to her obstetrician for a routine visit. Her blood pressure was previously normal, until her 24-week visit when it was measured at 142/92 mm Hg. Today, her blood pressure is 144/92 mm Hg. She reports no vision changes, headache, or abdominal pain. Urinalysis is significant for 2 protein. Complete blood count and kidney function testing is unremarkable. Which of the following is the most appropriate treatment at this time?
Continued monitoring Continued monitoring is the most appropriate management for the patient in the vignette because her blood pressure is < 160/110 mm Hg, and she does not have any evidence of end-organ dysfunction. dx:Preeclampsia Patients with risk factors should be offered low-dose aspirin therapy to reduce the risk of developing preeclampsia. Definitive treatment for preeclampsia is delivery, but the timing of delivery depends on the gestational age, severity of preeclampsia, and maternal and fetal condition delivery at 37 weeks (without severe features) and 34 weeks (with severe features) AND prevention of seizures with magnesium sulfate and prevention of permanent maternal organ damage New-onset hypertension < 20 weeks gestation: suspect molar pregnancy Risk factors for preeclampsia include a past history of preeclampsia, pregestational diabetes, chronic hypertension, antiphospholipid syndrome, body mass index > 30 kg/m2, nulliparity, multifetal pregnancy, and advanced maternal age. Antihypertensive therapy to prevent stroke is indicated for patients with systolic blood pressure of ≥ 160 mm Hg or diastolic blood pressure of ≥ 110 mm Hg, but it does not prevent eclampsia.
An 18-year-old woman presents to the clinic with recurrent pelvic pain each month with the onset of menses. Which of the following best describes the classic pain of the most likely diagnosis?
Crampy and midline DX:Dysmenorrhea (painful menstruation) The first-line pharmacologic treatments for primary dysmenorrhea are nonsteroidal anti-inflammatory drugs, hormonal contraceptives, or both. Combined (estrogen and progestin) oral contraceptives or progestin-only contraceptives are equally effective.
A 35-year-old woman presents to a women's health clinic requesting oral contraceptive therapy. The physician assistant decides to prescribe a combined estrogen-progestin hormonal contraceptive. Which of the following is a relative contraindication to combined estrogen-progestin oral contraception for this patient?
Current tobacco use of 10 cigarettes/day Body weight > 198 lbs (90 kg) (A) is a relative contraindication for the transdermal contraceptive patch but is not a contraindication to oral contraceptives. History of stroke (C) and migraine with aura (D) are absolute contraindications to oral contraceptives, which are associated with an increased risk for cerebrovascular accidents in these patients.
A 25-year-old woman presents to her gynecologist with complaints of painful cyst-like masses in both breasts. She states her breast masses seem to fluctuate in size rapidly and they are the most painful right before her menstrual cycle begins. Ultrasound of the breasts reveals the presence of multiple small cysts bilaterally with no malignant or concerning features. Which of the following lifestyle modifications should be recommended for this patient?
Decreasing dietary fat intake DXFibrocystic diseas Which natural medication used to alleviate pain in fibrocystic disease is a form of gamolenic acid? Answer: Evening primrose oil. Studies concerning diet and lifestyle modifications for management of fibrocystic disease have shown mixed results. In general, decreasing dietary fat intake, decreasing caffeine intake, decreasing chocolate intake, and using evening primrose oil or vitamin E have been recommended to patients with fibrocystic disease
A 25-year-old nulliparous woman complains of dysmenorrhea that has become progressively worse over the past 2 years. Her pain is described as a constant, aching pain. It begins 2 to 7 days prior to onset of bleeding and does not subside until the menstrual flow decreases. In addition, she complains of pain with intercourse. She has never been pregnant and uses condoms and foam for contraception. You make the presumptive diagnosis of endometriosis. Which of the following is the BEST way to confirm the diagnosis definitively?
Diagnostic laparoscopy is the only definitive way to diagnose endometriosis.
A 23-year-old woman presents to the emergency department with right-sided abdominal pain, nausea, and vomiting that began suddenly about 30 minutes ago after she went to a group exercise class. She was recently diagnosed with polycystic ovarian disease. Upon physical examination, she does not have any tenderness to palpation to her abdomen or pelvis and there are no palpable masses or evidence of distension. A pregnancy test is negative. Which of the following is the best way to definitively diagnose her condition?
Direct visualization at the time of surgical evaluation DX:Ovarian torsion Why is the right-sided ovary more likely to torse than the left? Answer: Because the right utero-ovarian ligament is longer than the left and the sigmoid colon is on the left side, so the left ovary has less ability to move and twist Ovarian Torsion Patient will be a woman, 15-30 years old or postmenopausal Sudden onset of unilateral (right > left) abdominal and pelvic pain Labs will show leukocytosis Imaging will show enlarged ovary or ovarian mass Definitive diagnosis and management: laparoscopy.
A 23-year-old woman presents to the emergency department with right-sided abdominal pain, nausea, and vomiting that began suddenly about 30 minutes ago after she went to a group exercise class. She was recently diagnosed with polycystic ovarian disease. Upon physical examination, she does not have any tenderness to palpation to her abdomenor pelvis and there are no palpable masses or evidence of distension. A pregnancy test is negative. Which of the following is the best way to definitively diagnose her condition? Why is the right-sided ovary more likely to torse than the left?
Direct visualization at the time of surgical evaluation dx:Ovarian torsion torsion risk is increased in pregnancy, sudden onset of one-sided pelvic pain that is associated with nausea and vomiting. The pain can be precipitated by activity such as vigorous exercise or intercourse. A physical examination may reveal a low-grade fever in some patients, as well as tachycardia or elevated blood pressure associated with severe pain. An abdominal and pelvic exam may be negative for palpable masses Ovarian Torsion Patient will be a woman, 15-30 years old or postmenopausal Sudden onset of unilateral (right > left) abdominal and pelvic pain Why is the right-sided ovary more likely to torse than the left? Answer: Because the right utero-ovarian ligament is longer than the left and the sigmoid colon is on the left side, so the left ovary has less ability to move and twist. Labs will show leukocytosis Imaging will show enlarged ovary or ovarian mass Definitive diagnosis and management: laparoscopy
A 25-year-old G2P1 woman at 33 weeks gestation presents to the emergency department after feeling a gush of vaginal fluid 2 hours ago. On speculum examination, clear fluid is seen pouring out of the cervical os and pooling into the vaginal vault. Nitrazine testing reveals a pH of 7.2, and microscopic examination demonstrates a ferning pattern. Ultrasound is significant for oligohydramnios. Which of the following is the most common risk factor for the patient's condition?
Gardnerella vaginalis infection DXpreterm prelabor rupture of membranes (PPROM) What is the recommended route, dosage, and duration of metronidazole prescribed for pregnant patients with bacterial vaginosis? Answer: Metronidazole 500 mg PO bid for 7 days..
A 25-year-old G2P1 woman at 33 weeks gestation presents to the emergency department after feeling a gush of vaginal fluid 2 hours ago. On speculum examination, clear fluid is seen pouring out of the cervical os and pooling into the vaginal vault. Nitrazine testing reveals a pH of 7.2, and microscopic examination demonstrates a ferning pattern. Ultrasound is significant for oligohydramnios. Which of the following is the most common risk factor for the patient's condition?
Gardnerella vaginalis infection, is the single most common identifiable risk factor for preterm prelabor rupture of membranes (PPROM).
A 32-year-old woman who is lactating presents to the office due to localized breast pain and malaise. Relevant findings on physical exam include a temperature of 100.9°F with a fluctuate, tender, erythematous mass in the upper outer breast quadrant. The patient has attempted to treat her symptoms with warm compresses, massage, and a course of antibiotics prescribed by her primary care provider. Which of the following results would a culture of aspirated fluid most likely have?
Gram-positive cocci in clusters = s.arues bug common in breast abcess Usually a complication of mastitis Which risk factor is associated with recurrent breast abscesses? Answer: Smoking.
notation used for pregnancy history?
Gravida: number of times a woman have been pregnant Parity: Number of pregnancies that led to a birth either at or after 20 weeks T (term) 🡪 number born at 37 weeks or older P (preterm) 🡪 born after 20 weeks but before 37 weeks A (abortion) 🡪 all pregnancy losses prior to 20 weeks L (living) 🡪 infant who lives beyond 30 days
A 22-year old G1P1 woman undergoes a cesarean section at 37 weeks gestation because she is HIV positive and her RNA viral load is 1,500 copies/mL. She has a recent history of herpetic breast lesions 1 month ago that have resolved. She was successfully treated for tuberculosis 2 years ago. After a 5-year history of cocaine use, she quit upon becoming pregnant, and her current urine drug screen is negative. Case management has provided the patient with resources for obtaining affordable baby formula. Which of the following in the patient's history is a contraindication for breastfeeding?
HIV status or active TB untreated undergoing radiation antiretroviral medication chemotherapy infant galactosemia
A 28-year-old female is diagnosed with cervical intraepithelial neoplasia (CIN II) after a routine Pap smear. What is the treatment of choice at this time?
HSIL is associated with a high risk of CIN 2,3 or cervical cancer. In women 25 and older management with immediate colposcopy or LEEP is based upon these risks.
A 35-year-old woman undergoes a transvaginal ultrasound showing hypoechoic, round, and well-circumscribed uterine tumors. Which of the following is the most common symptom of the most likely diagnosis?
Heavy menses Structural causes: polyp, adenomyosis, leiomyoma, malignancy or hyperplasia (PALM) Nonstructual causes: coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified (COEIN) dx:Fibroids appear as hypoechoic, round, well-circumscribed masses on ultrasound. The treatment varies based on the patient's fertility plans. Hysterectomy is the definitive treatment, and fibroids are the most common indication for hysterectomy. The other procedures used to treat fibroids include myomectomy, endometrial ablation, and uterine artery embolization. However, medical therapy with a levonorgestrel-releasing intrauterine device is a common option for women who wish for the least invasive treatment. Fibroids usually become smaller or resolve in postmenopausal women.
A 38-year-old woman presents along with her 42-year-old husband to discuss difficulties conceiving. They have had consistent, unprotected intercourse for 8 months without a positive pregnancy test. She has never been pregnant, and he has never fathered a child. She has a history of regular menses occurring every 30 days. They both report no history of sexually transmitted infections. Neither individual has a family history of infertility or genetic diseases. Neither of them smoke or use illicit drugs, although they have an occasional drink with dinner. Which diagnostic study is most appropriate, according to this history?
Hysteroscopy and semen analysis ------------------------------------------- Hysterosalpingography is a procedure performed to evaluate for structural abnormalities of the cervix, uterus, or fallopian tubes as the cause of infertility. A hysterosalpingography would be an appropriate next step in the evaluation of female infertility Scrotal ultrasound would be performed after a semen analysis when evaluating for male infertility.
A 32-year-old G2P2 woman presents to the office due to left breast tenderness. She is 2 months postpatrum and had a normal vaginal delivery of a healthy baby girl. Her infant is entirely breastfed and has been gaining weight appropriately. Other than left breast tenderness and some redness that she noticed shortly before the appointment, she feels well. She has a history of mastitis with her first pregnancy. Her vital signs show a blood pressure of 119/77 mm Hg, pulse of 88 bpm, temperature of 98.6°F, and respirations of 10 breaths per minute. On physical exam, her left breast is engorged and has a 1.0 cm area of erythema and tenderness on the lateral aspect of the breast. There is no edema or dimpling of the skin. Milk is easily expressed from the left side. Which of the following is the most appropriate initial management for this patient while she continues to completely empty the involved breast?
Ibuprofen 800 mg PO as needed DX;Lactational mastitis The most common pathogens causing lactational mastitis are Staphylococcus aureus,
A 53-year-old woman presents to her primary care physician for a routine examination. She notes that she began having hot flashes several months prior to presentation along with occasional painful urination. She notes that her periods have become more frequent and irregular, but have become lighter overall. Which of the following is most likely to be true regarding this patient's levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), and androstenedione?
Increased FSH, increased LH, no change in androstenedione
A 36-year-old woman presents to her gynecologist with complaints of heavy menstrual cycles and dysmenorrhea for the past 5 months. She states her periods have previously been normal. She reports no dyspareunia or dyschezia. Pelvic examination reveals the presence of an enlarged, mobile, globular, boggy uterus with no adnexal tenderness. No cervical discharge is seen on speculum exam. Her urine pregnancy test is negative. Transvaginal ultrasound is significant for an enlarged uterus. Which of the following treatments is most appropriate for the suspected diagnosis?
Levonorgestrel-releasing intrauterine device DX:Abnormal uterine bleeding PALM-COEIN is used to remember various causes of abnormal bleeding: polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, endometrial, iatrogenic, and not yet classified
A 25-year-old woman presents to labor and delivery at 38 weeks gestational age with contractions. She reports she has had contractions every 5 minutes for the past 2 hours. Cervical examination reveals she is dilated to 4 cm. The patient is requesting pain medication. Which of the following is a relative contraindication to neuraxial analgesia? At which vertebral level is an epidural most commonly placed in obstetrics patients?
Local infection at the site of neuraxial analgesia puncture At which vertebral level is an epidural most commonly placed in obstetrics patients? Answer: L3-L4. --------------------------------------------------- The lowest effective dose of medication should be used to avoid adverse effects, such as motor block, maternal hypotension, placental drug transfer, and local anesthetic toxicity Pruritus is a common side effect and can be treated with small doses of opioid antagonists, such as naloxone or naltrexone
A woman reports to the office 2 days postpartum due to persistent bloody discharge. She describes the bleeding as red-brown and states it resembles her menstrual discharge. Which of the following is the correct name and appropriate duration of this discharge? post partum findings When does ovulation resume after childbirth on average?
Lochia rubra, which should subside in a few days The uterus returns to the pelvis after 2 weeks and achieves a normal, nonpregnant size after 6 weeks. Postpartum women may report menses-like bleeding followed by other forms of vaginal discharge, termed lochia. After the placenta separates from the uterine wall, the basal portion of the decidua remains. The superficial layer is shed while the deeper layer regenerates the endometrium. This initial shedding results in red or red-brown discharge (lochia rubra) that lasts for a few days following delivery. Lochia rubra is followed by lochia serosa, which has a pinkish-brown coloring that lasts for 2 to 3 weeks final yellowish-white discharge, termed lochia alba, is composed of serous exudate, erythrocytes, leukocytes, decidua, epithelial cells, and bacteria. 1) Telogen effluvium is the loss of hair in the resting stage and is a common concern 1 to 5 months following delivery. Normal hair patterns are generally restored after 6 to 15 months. Immediate weight loss from delivery of the fetus and placenta and from amniotic fluid loss is approximately 13 pound hospital stay following a vaginal birth is 48 hours, while patients who undergo cesarean delivery are admitted for 72 hours following the operation. When does ovulation resume after childbirth on average? Answer: After 45 days in nonlactating women and 189 days in lactating women.
A woman presents to the breast clinic with a new unilateral right-sided breast lesion. Physical examination reveals a well-circumscribed, nontender, and smooth 2.5 cm mass. Ultrasound reveals a solid and well-circumscribed lesion. Which of the following additional findings is consistent with the most likely diagnosis? f/u What are the disadvantages of surgical excision of an asymptomatic biopsy-confirmed fibroadenoma?
Mobile quality to the lesion dx:Breast fibroadenomas s/s:smooth, well-circumscribed, nontender, and mobile breast lump. follow-up repeat ultrasound in 3 to 6 months or a core-needle biopsy. Patients who have changes in the lesion on repeat ultrasound must have a biopsy performed to confirm the diagnosis. Patients with biopsy-proven fibroadenomas may have excisional surgery performed. What are the disadvantages of surgical excision of an asymptomatic biopsy-confirmed fibroadenoma? Answer: Scarring at the site, dimpling of the skin, and damage to the breast's duct system.
A 34-year-old African-American female G2P2002 presents with heavy menstrual bleeding. CBC shows a microcytic, hypochromic anemia. Physical exam reveals several smooth, spherical uterine masses. She and her husband would like have another child. Which of the following would be the best treatment option?
Myomectomy is a choice for a patient with symptomatic fibroids who would like to maintain fertility and retain the uterus. There is, however, a significant risk for recurrence of leiomyomas. Fibroids occur 2-3 times more often in black women than white women. ------------------------------------------------- Uterine fibroid embolization is a treatment choice (other than major surgery) for premenopausal patients for whom fertility is not a concern, but who would like to avoid a hysterectomy or the side effects of medical therapy.
A 27-year-old G2P1001 woman presents to labor and delivery at 33 weeks and 2 days of gestation with regular uterine contractions for 2 hours. She reports no vaginal bleeding or clear leakage of fluid. Pelvic examination reveals cervical dilation to 3 cm. Which of the following is the best recommendation for tocolytic therapy?
Nifedipine dx: preterm labor ( 20 - 36 wks of gestation Tocolytic drugs (e.g., indomethacin, nifedipine, magnesium sulfate, terbutaline) may be used to delay delivery for up to 48 hours to allow the antenatal corticosteroid to take full effect.
A 21-year-old woman presents to the office for lower abdominal pain and cramping for several days. She states that she had typical cramping and pain with her period but then continued to have pain even after menstruating. Her pain is across the lower abdomen and is constant. It is worse during intercourse, and she has been bleeding thereafter. She has multiple sexual partners and says that she does not always use barrier protection. A physical exam reveals some mucopurulent cervical discharge, and there is cervical motion tenderness on a bimanual exam. Which of the following studies should be ordered to help diagnose this condition? b) A 23-year-old woman presents to her gynecologist due to fever, nausea, vomiting, and lower abdominal pain. She is currently sexually active and uses condoms occasionally. Vital signs are T of 38.4°C (101.1°F), BP of 138/78 mm Hg, HR of 90 bpm, RR of 18 breaths per minute, and oxygen saturation of 99% on room air. Physical examination is significant for bilateral lower abdominal tenderness to palpation. Pelvic examination is significant for purulent endocervical discharge, cervical motion tenderness, and uterine tenderness without adnexal masses. The patient is sent to the ED and admitted for treatment. Which of the following is a complication of the most likely diagnosis? Why are women with a history of this disease at risk for ectopic pregnancy?
Nucleic acid amplification tests b) chronic pelvic pain dx:Pelvic inflammatory disease Why are women with a history of pelvic inflammatory disease at risk for ectopic pregnancy? Answer: Because pelvic inflammatory disease causes direct damage to the fallopian tube.
A 58-year-old woman presents to her primary care provider with complaints of urinary incontinence. She states that, sometimes, she cannot make it to the bathroom in time and wets herself. On speculum examination, the patient is asked to cough, which results in the leakage of a small amount of urine. Her urinalysis is unremarkable. She is diagnosed with mixed urinary incontinence. Which of the following treats urge incontinence rather than stress incontinence?
Oxybutynin = antimuscarinics and beta-adrenergics (e.g., mirabegron) vs stress induced is topical estrogen
A 24-year-old G1P0000 woman presents to the clinic at 36 weeks gestational age for a routine prenatal visit. Her blood pressure is noted to be 142/102 mm Hg and is 146/104 mm Hg on repeat measurement 4 hours later. She has no prior history of hypertension. Which of the following additional findings would support a diagnosis of severe preeclampsia? tx? Which medication can be offered to women with risk factors for preeclampsia to prevent preeclampsia?
Photopsias dx= preeclampsia criteria : proteinuria or end-organ features that develop after 20 weeks blood pressure ≥ 140/90 mm Hg on two occasions ≥ 4 hours apart Proteinuria ≥ 300 mg in a 24-hour urine collection what made it severe severe headache or headache that does not resolve with acetaminophen, visual disturbances (e.g., photopsia, scotomata), elevated creatinine, elevated liver function tests, thrombocytopenia, pulmonary edema, or abnormal fetal findings (e.g., growth restriction, oligohydramnios, evidence of fetal distress). The risk factors for preeclampsia include a personal or family history of preeclampsia, nulliparity, chronic hypertension, pregestational diabetes mellitus, and multiple gestation. thrombocytopenia <100,000 tx:Antenatal corticosteroids, such as betamethasone, are administered to women with preeclampsia who are < 34 weeks pregnant. Women with preeclampsia should be administered intrapartum and postpartum seizure prophylaxis with magnesium sulfate. Which medication can be offered to women with risk factors for preeclampsia to prevent preeclampsia? Aspirin.
A young otherwise healthy adult female complains of painful periods. Further history reveals that the pain occurs on the initial day of her menses and is associated with headaches. Which of the following will most likely be found on physical exam?
Physical exam usually does not reveal any significant pelvic disease with primary dysmenorrhea. At times, the patient may have generalized pelvic tenderness.
A 24-year-old woman presents to the emergency department after delivering a baby at a birthing center about 1 hour ago. She is pale and fatigued, with a blood pressure of 92/54 mm Hg and a heart rate of 124 beats per minute. She is wearing a pad that she states has been changed multiple times within the past hour and has been filled with bright red blood and clots. Which of the following placental complications has the greatest risk for postpartum hemorrhage due to the depth of invasion into the uterine myometrium?
Placenta percreta What are the four Ts (mnemonic) for causes of postpartum hemorrhage? Answer: Tone, trauma, tissue, and thrombin. Postpartum Hemorrhage Blood loss of ≥ 1,000 mL or bleeding associated with signs and symptoms of hypovolemia within 24 hours of birth regardless of route of delivery Most commonly caused by uterine atonyPE will show an enlarged boggy uterus ManagementEmpty bladderBimanual exam and uterine massageOxytocin and additional uterotonics (e.g., prostaglandins)Tamponade (balloon or surgery)
A 24-year-old G2P1 woman at 24 weeks gestation presents to her obstetrician for a routine visit. Her blood glucose for the 50 gram 1-hour glucose challenge test is 185 mg/dL. A 100 gram 3-hour glucose tolerance test is ordered, and her blood glucose is 110 mg/dL fasting, 205 mg/dL at 1 hour, 180 mg/dL at 2 hours, and 165 mg/dL at 3 hours. Her glucose challenge test was negative during her last pregnancy. Which of the following complications is associated with the patient's current condition?
Polyhydramnios Complications associated with gestational diabetes include preeclampsia, gestational hypertension, polyhydramnios, large for gestational age infant, maternal and infant birth trauma, perinatal mortality, and neonatal complications (e.g., shoulder dystocia, hypertrophic cardiomyopathy, hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia). dx gestational DM In shoulder dystocia, which maneuver is used initially to release an impacted shoulder by sharply flexing the mother's legs so that the thighs touch the abdomen? Answer: McRoberts maneuver.
A 24-year-old woman at 37 weeks gestation presents to the office for a routine obstetrics exam. An ultrasound reveals an amniotic fluid index of 4 cm and no signs of fetal abnormalities. Which of the following is a risk factor for this condition?
Preeclampsia dx:Oligohydramnios is characterized by a lower than normal volume of amniotic fluid, which can lead to underdevelopment of fetal lung tissue as well as fetal death most common cause of oligohydramnios is the rupture of membranes, by ultrasonography, which will show an amniotic fluid index < 5 cm or a single deepest pocket that is < 2 cm in depth. Women with diagnosed oligohydramnios should be put on bed rest with adequate hydration to promote the production of amniotic fluid. A thorough evaluation of the fetal anatomy should be done, as well as genetic testing as indicated. Fetal esophageal atresia (A), fetal hyperglycemia (B), and trisomy 21 (D) are risk factors associated with polyhydramnios (an overabundance of amniotic fluid), not oligohydramnios. oligohydramnios is more common than polyhydramnios.
A 29-year-old female presents to the gynecology office with complaints of headache, breast tenderness, and pelvic pain. She further admits to bloating and irritability. These symptoms predictably occur about a week before the onset of menses. What is the most likely diagnosis?
Premenstrual syndrome (PMS) includes the symptoms described. Other possibilities include labile mood, depression, anxiety, insomnia, hot flushes, and also changes in cognition (poor concentration, confusion). For a diagnosis of PMS, symptoms must occur in the luteal phase of the menstrual cycle second half), with a symptom-free time period of at least a week in the first half of the cycle. The symptoms must also occur in a minimum of two consecutive menstrual cycles.
A 21-year-old woman presents to her gynecologist with vaginal discharge for the past 2 days. She is sexually active with two male partners and occasionally uses condoms. A pelvic examination, Pap smear, wet prep, and nucleic acid amplification test are performed. Which of the following is associated with the most common bacterial cause of sexually transmitted infections?
Pyuria with no organisms on Gram stain dxChlamydia trachomatis is an intracellular gram-negative bacterium changes in vaginal discharge, bleeding between menses, and postcoital bleeding. Physical examination in symptomatic patients may show mucopurulent endocervical discharge, endocervical bleeding, or edematous ectopy.
A 55-year-old woman with a history of a genital human papillomavirus-16 infection presents to the clinic with vaginal pruritus and irritation. Physical exam reveals right vulvar skin lesions. Which of the following is the most likely description of the vulvar lesions for the suspected diagnosis?
Red and white ulcerative lesions dx:Vulvar cancer History of human papillomavirus (types 16, 18, 33) Vulvar lesion and pruritus PE will show unifocal vulvar ulcer, plaque, or mass, predominantly on the labia majora Most common type is squamous cell carcinoma (SCC) What gland is located in the posterior left and right vaginal introitus and secretes mucus? Answer: Bartholin gland.
A 36-year-old G2P2 woman with no history of prenatal care for her current pregnancy had a spontaneous home vaginal delivery at 35 weeks gestation and presents with her baby 2 hours after delivery because she thinks he is sick. The infant is admitted to the neonatal intensive care unit with skin edema, ascites, pericardial effusion, pleural effusion, and a hemoglobin of 4.9 g/dL. The mother had no prenatal or postnatal care for her first pregnancy, which occurred 3 years ago. Her first child was delivered vaginally at home without any complications. The mother reports cocaine use during this pregnancy. Which of the following is the most likely contributing factor for the infant's condition?
Rh incompatibility Hydrops fetalis is a complication of hemolytic disease of the fetus and newborn and is characterized by skin edema, ascites, pericardial effusion, pleural effusion, and severe anemia (e.g., fetal hemoglobin < 5 g/dL or a hematocrit < 15%). Thrombocytopenia and neutropenia may also be present. Rh Isoimmunization Rh-negative mothers exposed to Rh-positive blood → anti-Rh antibodies Subsequent pregnancies: jaundice, anemia, fetal hydrops, fetal death Anti-D globulin at 28 weeks (and within 72 hrs of delivery if infant is Rh+)
A 21-year-old female presents for an elective abortion at 10 weeks gestation. Which of the following would be the safest and most effective method?
Suction curettage is the safest and most effective method for termination of pregnancies up to 12 weeks. The majority of induced abortions in the US are via suction curettage.
two-step oral glucose tolerance test (OGTT) and tx
The two-step OGTT is the most commonly used in the United States, and it involves a f irst-step screening OGTT followed by a diagnostic OGTT. For the screening OGTT, a 50-gram dose of glucose is given without regard to fasting, and the patient's serum glucose level is measured 1 hour after the oral glucose load. If serum glucose concentrations after 1 hour are > 130 mg/dL, the screen is positive and the patient should progress to the diagnostic OGTT step (step-two). The diagnostic step is done by administering 100 grams of oral glucose to the patient after fasting for at least 8 hours. Serum glucose concentrations are measured before the glucose load and at 1-hour increments for 3 hours after the glucose load. The following serum glucose concentrations would be considered a positive test for gestational diabetes using the Carpenter/Coustan method: fasting glucose ≥ 95 mg/dL, 1-hour glucose ≥ 180 mg/dL, 2-hour glucose ≥ 155 mg/dL, and 3-hour glucose ≥ 140 mg/dL. TREATMENT All women diagnosed with gestational diabetes should be encouraged to adopt lifestyle changes to lower serum glucose concentrations (e.g., healthy eating and exercise). Regular and neutral protamine Hagedorn insulin are the first-line medications for gestational diabetes in women with persistently high fasting and postprandial serum glucose levels despite lifestyle modifications. Second-line medications for gestational diabetes include glyburide and metformin, both of which are safe to use in pregnancy.
risk factor of posters pregnancy
These infants will appear long, thin, and malnourished. Meconium staining may be seen. Vernix caseosa and lanugo hair are typically decreased or absent. Dry and parchment-like peeling skin may be seen in these infants, as well as loose skin over the thighs and buttocks. Scalp hair is increased and the nails are usually long. These infants may also have an alert or wide-eyed appearance.\ Fetal growth restriction in postterm infants is associated with infant hypoglycemia and polycythemia. Both macrosomic and small for gestational age infants are at increased risk of perinatal asphyxia, neonatal encephalopathy, meconium aspiration, congenital malformations, and persistent pulmonary hypertension. Induction at 41 weeks gestation is recommended to decrease the risk of these complications.
A 25-year-old woman presents to the emergency department with a painful, swollen left breast and low-grade fever. She reports she developed mastitis while breastfeeding about 2 weeks ago that initially improved with antibiotics. She reports smoking one pack of cigarettes daily but always outside, away from the baby. She is taking no medications other than acetaminophen. She no longer has pain with breastfeeding but has developed a hot, painful, swollen area on her breast. On exam, she is obese but otherwise appears well. Her left breast has a localized, indurated area of about 3 cmdiameter to the left of the areola, which is warm, tender to palpation, and fluctuant. Bedside ultrasound confirms the diagnosis and also facilitates aspiration of fluid. Which of the following elements of this patient's history puts her at greatest risk for this being a recurrent problem?
Tobacco use dx:breast abcess
A 54-year-old premenopausal woman is diagnosed with metastatic hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer, for which she is prescribed a single-agent therapeutic treatment. Which of the following is considered a black box warning associated with this medication?
Uterine malignancy and thromboembolic event for drug : tamoxifen A/d:hot flashes, corneal deposit , sarcoma ..... Age is the single most important risk factor for developing breast cancer Diagnostic mammography is used to evaluate a clinically evident mass, Core-needle biopsy of tumors can definitively diagnose a tumor as benign or malignant. Breast ultrasound is an alternative imaging study to evaluate suspicious lesions, with hypoechogenicity, internal calcifications, shadowing, a lesion that is taller than it is wide, and spiculated, indistinct, or angular margins suggesting malignancy.
A 52-year-old woman presents to the gynecology clinic with vaginal dryness. She also reports vaginal burning, dyspareunia, and urinary frequency. The patient reports no hot flashes. Pelvic examination reveals vulvovaginal erythema and fissuring. Which of the following is the initial first-line treatment for the most likely diagnosis?
Vaginal moisturizers and lubricants nitial first-line treatment+safety and possible efficacy. dx:Vulvovaginal (urogenital) atrophy s/s= vulvovaginal dryness, burning, and irritation; urinary symptoms, such as dysuria, urinary frequency, and recurrent urinary tract infections reduced lubrication during sexual intercourse causing dyspareunia. Systemic estrogen and progestin (A) is used as a hormone replacement therapy in women with other symptoms of menopause in addition to vulvovaginal atrophy, such as hot flashes and flushing. However, the patient in this vignette only had symptoms of vulvovaginal atrophy.
A 41-year-old nulliparous woman with a history of infertility presents to her gynecologist with nausea, vomiting, and pelvic discomfort. Her last menstrual period was 7 weeks ago. A serum human chorionic gonadotropin level is obtained and is 346,000 mIU/mL. A transvaginal ultrasound reveals the absence of amniotic fluid and a snowstorm pattern. The patient is scheduled for surgical treatment. Which of the following is the most appropriate follow-up for the patient after surgery?
Weekly monitoring of serum human chorionic gonadotropin until < 5 mIU/mL DX:Hydatidiform mole, also known as a molar pregnancy, is a type of gestational trophoblastic disease. What is the most common site of early hematogenous metastases of a choriocarcinoma? Answer: Lungs.
A 55-year-old female presents complaining of vaginal bleeding. LMP was 3 years ago; Pap smear is normal. An endometrial biopsy is performed. Which of the following histological cells types is most likely to be found? A 67-year-old nulliparous white female with a history of diabetes presents with postmenopausal bleeding. Further gynecologic history reveals menarche at age 10 and menopause at age 59. For the most likely diagnosis, which of the following is the most common type?
adenocarcinoma
A woman presents at 30 weeks gestation complaining of a slow constant trickle of fluid from her vagina x 3 days. Physical exam shows positive pooling in the posterior fornix and the ferning test is positive. External monitoring shows the fetal heart rate at 140 beats per minute with beat to beat variability and accelerations; biophysical profile is 10. What is the next step in management?
admit to hospital for bedrest and monitoring prophylactic antibiotics and maternal corticosteroids (to accelerate fetal lung maturity) may be administered as well. premature rupture of membranes (PROM)
A 42-year-old woman presents to the office due to increasing intermittent breast pain and tenderness that has gotten increasingly worse over the past year. She states the pain peaks about 1 week before her period. She has tried wearing more supportive bras and taking over-the-counter pain relievers for the past 6 months but nothing has helped. She feels like she is not able to work when she experiences this pain. She notices her breasts feel heavy and extremely tender, especially with physical activity. Physical exam reveals very dense breasts upon palpation with rope-like texture bilaterally. Which of the following therapy is the best next step for the treatment of her condition?
ans = Tamoxifen s/e = Hot flashes, vaginal dryness, joint pain, leg cramps. Tamoxifen also increases the risk of blood clots, stroke, uterine cancer, and cataracts. black box : uterine malignancy n thromboembolic dx:Fibrocystic breast changes Upon physical examination, the breast tissue may feel dense on palpation, with rope-like or cobblestoning texture. Fibrocystic changes are generally benign and do not increase the risk of breast cancer. multiple cysts or masses bilaterally, breast pain and tenderness, and occasionally, serous nipple discharge. Fluctuations in size and rapid appearance or disappearance Conservative treatment for a period of at least 6 months is the first-line treatment and includes wearing well-fitting and supportive bras, avoiding trauma to the breasts, applying heat to the breasts, and taking over-the-counter pain relievers to help alleviate symptoms. Women with more severe symptoms can be treated with second-line therapies such as tamoxifen or danazol.
A 36-year-old G2, P2 comes to your office complaining of heavy menstrual bleeding for the past year. The patient is bleeding through a super tampon and a heavy pad every hour of the first three days of her cycle. Her cycle lasts 5 days and the cycle length has decreased to having a period every 20 days. She complains of fatigue. Her physical examination and laboratory work-up are normal (negative β-hCG, luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin, clotting times, liver function, and renal function tests), except for the complete blood cell count (CBC) and further labs indicating she has iron deficiency anemia. The patient's weight is 298 lb. In addition to iron supplementation, which of the following is the BEST INITIAL therapy for this patient?
oral contraceptives
A 25-year-old woman presents for follow-up 6 months postpartum because she has not menstruated since her vaginal delivery. She also mentions that she was not able to produce milk to breastfeed. You review her records from her labor and see that she had a postpartum hemorrhage resulting in hypotension that persisted for an hour. However, she did not have any instrumentation performed during the postpartum period. Her pregnancy test is negative. Which of the following diagnoses is this patient's presentation most concerning for?
dxSheehan syndrome s/sfailure to lactate after delivery and amenorrhea or oligomenorrhea. Patients with postpartum hemorrhage who remain hypotensive after the bleeding is controlled and volume is corrected should be empirically treated for adrenal insufficiency. The patient can be evaluated for other hormone deficiencies 4-6 weeks postpartum.
A 25-year-old patient is complaining of depression and anxiety just prior to her menses. The symptoms have been going on for more than 1 year, but are now starting to interfere with her relationships and her productivity at work. One week prior to menses each month she experiences a depressed mood, a feeling of being on edge, increased irritability, difficulty sleeping, a feeling of being overwhelmed, and is easily fatigued. She charted her symptoms daily in a log and returned to the office two cycles later. The log is consistent with the history. Her physical examination and general laboratory profile showed no abnormalities. Which of the following is the MOST effective treatment choice for this disorder?
fluoxetine premenstrual dysphoric disorder (PMDD). treatment of mild to moderate symptoms, lifestyle and dietary changes may be effective. Therefore, a trial of regular aerobic exercise, decrease in caffeine and alcohol intake, 1,200 mg of dietary calcium with 800 IU of Vitamin D per day, and eating complex carbohydrates as opposed to simple sugars could be initiated. For patients whose symptoms affect jobs and relationships, it is warranted to prescribe serotonin reuptake inhibitor such as fluoxetine. Fluoxetine 20 mg can be taken daily or only premenstrually.
A 25-year-old woman who delivered her child 2 days ago is visited by a lactation consultant, who explains to her the importance of breastfeeding, especially before the body produces mature milk, due to the benefits of colostrum for the baby. Which of the following components is found in high quantities in colostrum?
immunoglobulins (such as secretory IgA), lactoferrin, leukocytes, and macrophages that provide passive immunity for the infant. Colostrum also has a higher protein content than mature milk. Mature milk contains much less protein but is higher in water, carbohydrate, and fat content.
A 28-year-old female describes a one year history of weight gain, irritability and increased tension which occur 5 days before onset of menses. Which of the following dietary modifications will most likely decrease her symptoms?
limiting caffeine premenstrual syndrome Limiting caffeine, alcohol, tobacco, and chocolate has been found to help with some patients.
A first-time mother presents to the obstetric clinic with breast pain 2 weeks after giving birth. She has had some difficulty with breast feeding, as her newborn has not been able to latch onto her nipples easily. Exam reveals a painful and erythematous lobule in the outer quadrant of her left breast. What is the most appropriate treatment plan?
mastitis, milk stasis can be averted by continuing breast feeding or the utilization of a breast pump. Local warm compresses to the breast, a well-fitting undergarment, and antibiotic treatment (i.e. cephalosporins, methicillin, or dicloxacillin)
If RhD incompatibility is suspected due to parental genetics,
maternal anti-D titers should be measured serially until a critical titer level (usually 1:16 or 1:32) is reached, at which time, Doppler velocimetry of the middle cerebral artery of the fetus should be measured. Increased velocity through the middle cerebral artery correlates with decreased hemoglobin. If the velocity, once adjusted for gestational age, indicates critical fetal anemia, then cordocentesis should be performed to measure fetal hemoglobin and determine the need for transfusion. What outdated technique for measuring fetal anemia has largely been replaced by Doppler velocimetry? Answer: Amniocentesis to determine amniotic fluid bilirubin level.
one-step 75-gram OGTT can be performed on a fasting patient
may over-diagnose gestational diabetes. As such, the American Academy of Obstetrics and Gynecology does not recommend using it to screen for gestational diabetes.
A 22-year-old obese female presents complaining of anovulation and hirsutism. Testosterone levels are mildly elevated and LH/FSH ratio is 4. She does not wish to become pregnant at this time. Which of the following is the best treatment?
medroxyprogesterone acetate polycystic ovarian syndrome (PCOS)
A 26-year-old G1P0 at 14 weeks has consistent blood pressure readings of 166/110 despite sodium restriction and avoidance of alcohol and tobacco. There is no evidence of end organ damage; urinalysis is normal. What is the first line anti-hypertensive therapy for this patient?
methyldopa
A woman has undergone a suction curettage for a hydatidiform mole and was diagnosed with benign gestational trophoblastic neoplasia (GTN). Following this INITIAL treatment, which choice of monitoring should be done for patients in order to prevent the development of choriocarcinoma?
monitor serum radioimmunoassay β-hCG once per week until three to four normal values are obtained, and then monthly for 6 months to 1 year
A 32-year-old G2P1001 presents at 27 weeks gestation. Glucose challenge returns at 165 mg/dl. Results of a glucose tolerance test are: fasting: 90 mg/dl 1-hour: 195 mg/dl 2-hour: 145 mg/dl 3-hour: 130 mg/dl
no gestational diabetes Normal values are: fasting: <95 mg/dL; 1-hour: < 180 mg/dL; 2-hour: < 155 mg/dL; 3 hour: < 140 mg/dL.
Which of the following elements of a patient's history is the greatest risk factor for endometrial cancer?
postmenopausal bleeding
Postpartum hemorrhage
preventative measures to decrease the risk of uterine atony include oxytocin infusion, gentle cord traction, and uterine massage. Nonfatal cases of postpartum hemorrhage can result in sequelae such as adult respiratory distress syndrome, coagulopathy,shock, loss of fertility, and pituitary necrosis (Sheehan syndrome).
Which of the following in a pregnant patient's history would be a contraindication for a trial of labor after Cesarean section?
prior vertical uterine incision
A man and woman in their 20s have been trying unsuccessfully to conceive for the last year. The woman has regular menses and a 28-day cycle. In the initial evaluation, which of the following tests or evaluations should be considered first line?
semen analysis (1) does the woman ovulate? (if not, why not); (2) does the semen have normal characteristics? (3) is there a female reproductive tract abnormality? Noninvasive tests should be done first line. For the male partner, semen analysis is noninvasive and helpful, though not diagnostic. In the initial evaluation of the female partner, noninvasive procedures, such as the measurement of LH and mid-luteal phase progesterone (to determine ovulatory function) and TVUS (to rule out the possibility of fibroids or polycystic ovaries), are first-line investigations. Pelvic ultrasound should also be part of the routine gynecologic evaluation because it allows a more precise evaluation of the position of the uterus within the pelvis and provides more information about its size and irregularities. Hysterosalpingography is an invasive procedure and therefore not first line in the evaluation. Endometrial biopsy and postcoital testing are no longer recommended for the routine infertility evaluation because they have poor predictive value.
A 72-year-old woman presents to the office with complaints of a new vaginal mass. While she was cleaning her house earlier in the day, she reports feeling a sudden fullness vaginally. She is worried her bladder is falling out. She is experiencing some discomfort that is worse when she is sitting. On physical exam, the external genitalia appear normal, and there is no frank blood. When the patient performs a Valsalva maneuver, the uterine cervix protrudes through the vaginal introitus by 5 mm. When relaxed, the prolapse is completely reduced. Bimanual exam reveals a 4 cm uterus with a smooth contour and no adnexal masses. There is anterior vaginal wall laxity. Which stage of pelvic organ prolapse is this patient experiencing?
stage 3 stage 0 (no evidence of prolapse), stage 1 (prolapse further than 1 cm from the vaginal introitus), stage 2(prolapse ≤ 1 cm to the vaginal introitus), stage 3 (prolapse outside the vaginal introitus but by no more than 1 cm), and stage 4 (prolapse ≥ 1 cm outside the vaginal introitus). Risk factors for pelvic organ prolapse include advancing age, parity, obesity, menopause, and chronic constipation (which leads to straining). complain of feeling as if they are sitting on a ball. Depending on whether the patient has a cystocele or rectocele, they may also complain of difficulty with urination or defecation. They may require splinting, or placing two fingers vaginally and manually reducing the prolapse, to have a bowel movement. They may also experience vaginal dryness, pressure, discomfort, or bleeding. Valsalva maneuver will help with identifying the stage of prolapse. a vaginal exam using a speculum will reveal the condition of the vaginal walls and cervix. A bimanual exam will assist in determining the size and contour of the uterus as well as any adnexal masses. The diagnosis of pelvic organ prolapse is made based on history and physical exam. Small, asymptomatic prolapses may be managed expectantly. Instructing the patient on pelvic floor exercises or referring the patient to pelvic floor rehabilitation may help with strengthening the pelvic floor muscles. For symptomatic prolapse, a pessary device may be indicated. A pessary is a smooth, nonabsorbent, rubber device of various shapes and sizes that the patient is able to insert and remove herself.
A 39-year-old woman, G3, P3, complains of severe, progressive secondary dysmenorrhea and menorrhagia. Pelvic examination demonstrates a tender, diffusely enlarged uterus with no adnexal tenderness. Endometrial biopsy findings are normal. Which diagnostic examination is needed next?
transvaginal and abdominal ultrasound imaging diagnosis of adenomyosis
Metronidazole 2 g orally as a single dose or 500 mg twice daily for 7 days is the treatment regimen for which of the following vaginal infections?
trichomoniasis
A 13-year-old female presents 15 months after initial onset of menses. Her cycles have been irregular in timing as well as severity of bleeding. At times the bleeding is so heavy she misses school. Which of the following would be the most appropriate initial diagnostic step?
ultrasonography
Which of the following vitamins, if taken in excess, is teratogenicin the first trimester and is associated with spontaneous abortion and fetal malformation
vitamin A intake, particularly at the beginning of the first quarter of pregnancy, are congenital malformations involving the central nervous and cardiovascular systems and spontaneous abortion
Proper nutrition during the prenatal period weight protein carb fib iron calcium, negates what vit D , negates what folate , vs hx of neural tube defect iodine , what happens when too much Excessive intake of which micronutrient during pregnancy is associated with fetal goiter?
weight [BMI of 18.5-24.9 kg/m2 should gain 25-35 lbs over the course of the entire pregnancy. Patients with a prepregnancy BMI < 18.5 kg/m2 should gain 28-40 lbs during pregnancy, patients with a prepregnancy BMI of 25.0-29.9 kg/m2 should gain 15-25 lbs during pregnancy, and patients with a prepregnancy BMI ≥ 30.0 kg/m2should gain 11-20 lbs during pregnancy.] caloric need of the mother increases by approximately 340 kcal/day in the second trimester and 450 kcal/day in the third trimeste protein intake of 1.1 g/kg/day is recommended, up from 0.8 g/kg/day for nonpregnant women. A carbohydrate intake of 175 g/day is recommended, up from 130 g/day for nonpregnant women. Fiber intake should be around 28 g/day with plenty of fluid intake to reduce constipation. iron 27 mg, calcium 1,000 mg, vitamin D 600 IU, folate 600 mcg, and iodine 220 mcg Women who have had a previous neural tube defect-affected pregnancy should consume 4,000 mcg of folic acid daily. Iron supplementation is important for correcting or preventing iron deficiency anemia. Women with a first- or third-trimester hemoglobin < 11 g/dL, a second-trimester hemoglobin < 10.4 g/dL, or a serum ferritin < 40 ng/mL should receive an additional iron supplement of 30-120 mg/day until the anemia is corrected. Adequate calcium intake may reduce the risk of developing a hypertensive disorder during pregnancy. Adequate vitamin D levels are associated with a lower risk for a small for gestational age infant. Excessive intake of which micronutrient during pregnancy is associated with fetal goiter? Answer: Iodine.
