Ob/Gyn PA Easy

A patient presents to the office at 5 weeks gestation. She has been spotting for several days, and the flow is increasing slightly. She has mild, crampy pain; no fetal heart tones are auscultated. Ultrasound reveals an intrauterine gestational sac with a fetal pole. What is the most likely diagnosis? A Threatened abortion B Spontaneous abortion C Incomplete abortion D Septic abortion E Ectopic pregnancy

A Threatened abortion While she is at risk for a spontaneous abortion, one cannot determine fetal viability with one exam. Serial exams are necessary. Fetal heart tones are not always present at 5 weeks.

Atrophic vaginitis

Atrophic vaginitis (A) occurs primarily in postmenopausal women and is characterized by a thin watery or serosanguinous discharge, while bacterial vaginosis (B) has a greyish homogeneous discharge with a characteristic "fishy" odor released when potassium hydroxide is mixed with vaginal secretions

Which of the following is the drug of choice for treating herpes simplex virus (HSV) types 1 and 2? A amantadine B acyclovir C zidovudine D nystatin E zanamivir

B acyclovir

A 19-year-old female patient presents to her family practice office for her annual Pap test and her first dose of the quadravalent human papillomavirus (HPV) vaccine. As her physician assistant, when would you schedule her to come in for her second dose of the HPV vaccine?

B two months The dosing and administration schedules are the same for HPV4 and HPV2. Each dose is 0.5 mL, administered intramuscularly, preferably in a deltoid muscle. The vaccines are administered in a three-dose schedule. The second dose is administered one to two months after the first dose, and the third dose is administered six months after the first dose.

You are providing care to a woman who is at 33 weeks gestation. Her pregnancy is complicated by gestational diabetes. She is being provided education by the dietician, and has weekly obstetrical appointments. What fasting blood sugar (FBS) readings should necessitate switching from diet control to insulin therapy?

C FBS > 95 mg/dL The Correct Answer is: C Gestational diabetes has different risks associated with it, in particular for the fetus. Stricter glycemic controls are recommended for pregnant versus non pregnant women by the ACOG and the ADA.

A 26-year-old female presents to clinic complaining of increasing headaches for one year, irritability, bloating and fluid retention, and abdominal discomfort with loose stools during her menstrual cycle. The symptoms begin a day or two before her menses, and last until the middle of her cycle. She has tried acetaminophen and ibuprofen without improvement. On physical exam she is a well-developed, well-nourished female in no acute distress. Vitals are normal, CV and lungs are normal, pelvis exam is normal, pap smear is normal, and GC and Chlamydia testing are negative. What would be the most appropriate next step?

C Fluoxetine on cycle day 21-7

A 33-year-old woman presents with an itchy vaginal discharge for the past 2 days. She has been healthy other than a recent sinus infection for which she took a 10-day course of amoxicillin. Her husband is her only sexual partner and he has no symptoms. On examination, the vulva is noted to be slightly erythematous and swollen with some evidence of excoriation. Discharge is white and clumpy. Provided the most likely diagnosis is confirmed on microscopy, first-line therapy is

C fluconazole 150 mg i po × 1 day

A woman presents for a routine post-partum checkup four weeks after delivery of her child. She is currently breast feeding without difficulty. She tells you that she has been feeling anxious and very warm, despite the change of season into winter. She is happy as a mother and has not had problems caring for her baby. What is the next best step in the investigation of her symptoms? A Radioactive iodine uptake test B Serum total T4 level C Thyroid fine needle aspiration D Serum TSH level E MRI of the anterior pituitary

D The correct choice is D, serum TSH level. This patient is presenting with post-partum thyroiditis. Thyroid dysfunction occurs in 2 to 5% of women after giving birth. It can recur with subsequent pregnancies and develop into long-term thyroid disease as well. Typically, women with this disorder first develop signs and symptoms of hyperthyroidism, which then later changes to hypothyroidism. Most symptoms resolve spontaneously within a few months

A 37-year-old female presents to the clinic for her obstetrical appointment. She is a G5P4 African American female. On physical exam her uterus is larger than expected for dates by 5 cm. What is her risk of having twins increased by? A Her increasing age B Her increasing parity C Her race D Her use of clomifine E Her late age of menarche

D. clomifine

A 28-year-old woman presents to the clinic after feeling a lump in her left breast. The patient has no past medical history and takes no medications. Family history is remarkable for her mother who survived breast cancer at the age of 44. On physical exam, a firm, well-circumscribed, mobile lump less than 1 cm in width can be appreciated in the upper outer quadrant of the left breast. What is the most likely diagnosis?

DISCUSSION: This patient's presentation is consistent with a fibroadenoma. Fibroadenomas are the most common type of solid benign breast tumor. They are common in younger patients. A fibroadenoma presents as a rubbery, painless, small, mobile mass. The next appropriate step in the care of this patient is an ultrasound. Ultrasonography to evaluate a breast mass is indicated in patients under 30 years of age, while ultrasonography plus mammogram is indicated in patients over 30 years. Younger women's breasts are more dense, limiting the sensitivity of mammography.

Which of the following tests should an HIV-positive pregnant woman undergo in each trimester of pregnancy? A CD4+ lymphocyte count B cytomegalovirus serology C postpartum depression with controls D shielded chest radiography E venereal disease research laboratory (VDRL)

HIV-positive pregnant women should undergo CD4+ serology each trimester

A newborn male is found to have the urethral opening on the ventral side of his penis. Figure A demonstrates this defect in an adult. This abnormality is a result of which of the following? Topic Review Topic

Hypospadias is a congenital anomaly resulting from incomplete fusion of the urethral (urogenital) folds.

A 33-year-old returns to clinic for reevaluation of her dysmenorrhea. She is a G3P3 who menstruates every 27 days. She has had a tubal ligation. She is a non-smoker. She has tried Tylenol (acetaminophen) and just completed 3 months of ibuprofen 800 mg TID x 7 days, starting 2 days before her menstrual cycle. She had only mild improvement of her symptoms. What should be the next step in management of her symptoms? A Norgestimate/ethinyl estradiol B Acetaminophen/ tramodol C Acetaminophen/ codeine D Cyclobenzaprine E Paroxetine

Primary dysmenorrhea is associated with ovulation, so suppression of ovulation in a woman who no longer desires fertility usually improves symptoms

Reiter syndrome

Reactive arthritis (also known as Reiter syndrome) is a result of an untreated chlamydia infection, and although typically characterized, in texts, by the triad of urethritis, arthritis, and conjunctivitis, all of the symptoms may not be present or not identified at the time of presentation.

A 37-year-old G3P2 female at 39 weeks gestation presents to the labor and delivery unit complaining of abdominal pain. Laboratory evaluation reveals anemia coagulopathy that is felt to be consumptive. What is the most likely diagnosis to have caused this?

Reproductive placental abruption is the most common cause of coagulopathy in pregnancy; the hemorrhage may be concealed and is not always evident. In the presence of pain, anemia, and coagulopathy, abruption should be assumed until proved otherwise

You are caring for a 33-year-old G3P2 women. Her PMH is significant for obesity and allergies. She receives routine obstetrical care. When is she due for her glucose challenge testing to rule out gestational diabetes?

Routine surveillance for gestational diabetes of a pregnant women is between 24 and 28 weeks

A 21-year-old female presents to clinic complaining of mild, low abdominal ache and intermittent dysuria. She denies N/V/D, and she is sexually active and uses condoms some of the time. Her LMP was 10 days ago, and she is a G0P0. Physical exam reveals a healthy female in no acute distress. Vitals are as follows: P 70, BP 120/80, T 99.9°F. Lungs are clear, CV RRR, abd soft non-tender, + BS. Pelvic exam reveals normal external genitalia, scant discharge, moderate cervical motion tenderness, and no adnexal masses. What is her most likely diagnosis? A Tubo-ovarian abscess B Gastroenteritis C Ectopic pregnancy D Cervicitis E Pelvic inflammatory disease

Suspicion for PID should be very high in a young, healthy, and sexually active woman with cervical motion tenderness. She is not spotting and just menstruated, making ectopic pregnancy much less likely.

A 33-year-old G1P0 presents for evaluation of her inability to conceive a pregnancy for six months. She menstruates monthly. Her past medical history is significant for PID x 2, for which she was hospitalized for IV antibiotics. Her Chlamydia, GC, and pap smear are normal. When should a more comprehensive evaluation for her infertility begin?

The Correct Answer is: A A comprehensive work up should begin now, due to her advancing age and history of significant PID, which may require surgical treatment

A 23-year-old woman presents with complaints of pelvic discomfort and a vaginal discharge for the past 3 days. She finished her period last week. She is taking oral contraceptives as directed. Her medical history is significant for a therapeutic abortion with no other hospitalizations or pregnancies. She has had three sexual partners in the past 6 weeks and does not use condoms. Her most recent partner reported that he was treated recently for gonorrhea. On examination, she has a mucopurulent discharge with "strawberry" cervix on speculum examination. After collecting the appropriate specimens, the best therapeutic option for this patient is

The Correct Answer is: A Clinical presentation is consistent with cervicitis in a young woman with risk factors for sexually transmitted infection. She has likely been exposed specifically to Neisseria gonorrhea. Coinfection with Chlamydia trachomatis is common. While test results are pending, the Centers for Disease Control and Prevention in its 2006 Guidelines for STD treatment recommend treating for both with single doses (improved compliance) of ofloxacin and azithromycin first-line.

A 40- year-old female patient comes to the office because she notices that she is easily fatigued but cannot pinpoint a direct cause of her fatigue. She has experienced muscle tenderness to the shoulders and other large muscle groups, sensitivity to touch these areas, and has also felt depressed lately. Based on this history and the vague physical exam findings, what is the most likely diagnosis?

The Correct Answer is: A Fibromyalgia syndrome (FMS) primarily affects woman between the ages of 20 and 60 and is now the second most common condition seen in rheumatologists' offices behind only rheumatoid arthritis. This condition spares the joints, but causes tender areas throughout the soft tissue as well as generalized pain and fatigue. There are several common trigger points, both anteriorly and posteriorly that help confirm the diagnosis. Polyarteritis nodosa is a systemic necrotizing vasculitis that generally affects medium size muscular arteries. Patients can present with many of the same symptoms as those with fibromyalgia (fatigue, muscle pain, and others), but these patients often have skin manifestations, joint pain, and fever, along with renal, GI, and cardiovascular signs not seen in fibromyalgia. Polymyositis is an inflammatory condition of the muscles that is characterized by proximal muscle weakness, with much less pain than is seen in fibromyalgia. Despite the proximal muscle weakness there is generally not significant atrophy

You are treating a 14-year-old female for gonorrhea. She has a past history of Chlamydia. Her LMP was 3 weeks ago. She is allergic to penicillin. Her only medication is oral combination birth control pills. Why should Levofloxin be avoided in this patient?

The Correct Answer is: A Fluoroquinolones are contraindicated in pediatric patients. The risk-benefit assessment indicates that levaquin is only appropriate in pediatric patients at least 6 months of age, for treatment of inhalational anthrax (post-exposure). There are other medications, both oral and injectable, with better safety profiles that are available.

You are providing care for a 28-year-old who presents to clinic for her 27-week obstetrical check. She has no complaints and the fetus is active. Physical exam reveals the following: P 88, BP 142/90, FHT 148, UA negative. CBC is normal. Her BP pre-partum was 110/70. What is the most likely diagnosis at this point? A Pregnancy induced hypertension B Preeclampsia C Eclampsia D Chronic hypertension E stress

The Correct Answer is: A HTN is one of the triad of symptoms of preeclampsia, but at this point there are no other symptoms or proteinuria. She will need to be carefully monitored, as 50% of these presentations will progress to preeclampsia.

A 22-year-old sexually active woman presents for her annual gynecologic evaluation. She reports one partner for the past 6 months and takes oral contraceptive pills as directed. Her periods have been regular. Her examination is unremarkable and her Pap smear returns with atypical squamous cells of undetermined significance and positive for human papillomavirus-16. The next most appropriate step for this patient is to A proceed with colposcopy B repeat Pap smear in 12 months C repeat Pap smear in 24 months D schedule her for a loop electrosurgical excision procedure (LEEP)

The Correct Answer is: A Human papillomavirus subtypes 6, 11, 16, and 18 increase risk for the development of cervical cancer. In a young woman over 21 years old with atypical squamous cells of undetermined significance and positive HPV 16 subtype, the next step in evaluation is the colposcopic evaluation. Alternatively, she could be followed with Pap smears at 6 and 12 months. The LEEP procedure is indicated for those with recurrent histologic finding of cervical intraepithelial neoplasm grade 2 or 3.

A 30-year-old G 2 P 1 woman comes to the emergency department at 37 weeks gestation with a chief complaint of worsening abdominal pain for the past two hours. On examination, the uterus is tense and tender. External fetal monitoring indicates frequent uterine contractions with late decelerations. An ultrasound suggests a retroplacental hemorrhage. What is the most appropriate course of action at this time? A Emergency operative delivery B Expectant management at home C Monitoring in the labor suite with the mother on her side D Tocolytic administration until the infant is 38 weeks gestation E Vaginal delivery with induction

The Correct Answer is: A Indications for emergency cesarean delivery in a woman with placental abruption include fetal heart tracings that are not reassuring. Furthermore, a retroplacental hemorrhage carries a direr prognosis than a subchorionic one.

A 34-year-old woman presents for her obstetrical checkup. She is a G2P1 and her pregnancy is uncomplicated to date. During her visit, what is the most important predictor of fetal well-being? A Normal maternal vitals and fetal activity B Maternal weight gain and fetal activity C Absence of contractions and fetal activity D Normal maternal vitals and absence of contractions E Maternal weight gain and normal maternal vitals

The Correct Answer is: A Maternal vitals are a sign of maternal well-being; combined with normal fetal activity, this gives the best predictive value for fetal well-being without direct fetal surveillance.

A woman who is pregnant suffered a spontaneous abortion at 12 weeks gestation. She is now a G2P1Ab1 and is Rh negative. When should she receive her next Rhogam (Rho D immune globulin) shot? A Now B In one month C At conception of her next pregnancy D 28 weeks gestation of next pregnancy E After delivery of her next viable infant

The Correct Answer is: A Placental implantation occurred and separated with the spontaneous miscarriage. Therefore, there is a slight chance of isoimmunization, so Rhogam should be given now so that the mother does not develop antigens that can cross the placenta during the first half of the next pregnancy.

A 30-year-old woman presents to the office with polyuria, fatigue, and a chronic white vaginal discharge with vaginal pruritis. She has been having the discharge off and on for the past 6 months with recurrent treatment failures. Which of the following is the most likely diagnosis? A type 2 diabetes mellitus B hyperthyroidism C hypothyroidism D diabetes insipidus

The Correct Answer is: A Polyuria, polydipsia, and fatigue are all findings that can be consistent with both type 1 and type 2 diabetes. Any woman who presents with a chronic vaginal discharge or chronic vaginal pruritis should be screened for type 2 diabetes.

A 37-year-old woman, G3P2 at 30 weeks gestation, complains of lower extremity swelling and her weight is up 5 pounds this week. Her PMH is insignificant, and her other pregnancy was uncomplicated. Her BP baseline is now 142/92. On exam her BP is unchanged, her UA shows 2+ protein, and FHTs are 152. What is the cause of the protein in her urine? A Glomeruloendotheliosis B Glomerulonephritis C Renal vasospasm D Glomerular hemorrhage E Glomerular infarct

The Correct Answer is: A The classic histological change that occurs in the renal system (in preeclampsia) is swelling and inflammation of the endothelium and of the glomeruli, which leads to endothelial leaking.

A sexually active 19-year-old woman presents with clusters of painful vesicles on an erythematous base on the vulva and cervix, accompanied by temperature of 100°F and mild malaise. She reports a history of a similar outbreak last month, which resolved in 10 days. Microscopic examination of cells from the basement of a blister treated with Giemsa stain is likely to reveal A multinucleated giant cells B gram-positive cocci in clusters C gram-positive cocci in chains D gram-negative rods E hyphae and buds

The Correct Answer is: A The clinical presentation is consistent with herpes simplex. The appropriate microscopic study is a Tzanck smear, prepared by staining cells from the floor of a vesicle using Papanicolau, Giemsa, or Wright methods.

A 54 year-old female returns for pathology results after being diagnosed with ovarian cancer. Which of the following is the most likely cause of ovarian epithelial malignancy? A Serous tumors B Endometrioid tumors C Mucinous tumors D Clear cell tumors E Transitional cell tumors

The Correct Answer is: A The most common of the ovarian epithelial malignancies are serous tumors (50%); tumors of mucinous (25%) (C), endometrioid (15%) (B), clear cell (5%) (D), and transitional cell (E) histology or Brenner tumors (1%) represent smaller proportions of epithelial ovarian tumors. Over half of all epithelial ovarian cancers have serous histology. The second most common histologic type of epithelial ovarian cancers are endometrioid adenocarcinomas.

A 27-year-old G3P2 at 39 weeks gestation has been in labor for 6 hours. Her membranes ruptured 3 hours ago and revealed a large amount of clear fluid. She has previously delivered a 7 pound 2 ounce infant. She is having good quality contractions, and has been completely dilated and pushing for 55 minutes. The fetal head is +4, FHT 128. What would be the most appropriate management at this time? A Continue pushing B Instrument delivery C Emergency caesarean section D Non emergent caesarean section E Epidural pain control

The Correct Answer is: A This is a multigravida patient with an adequate pelvis. She is making steady progress and there are no signs of maternal or fetal distress, so continued labor management is expected.

A 54-year-old female presents to clinic complaining of vaginal fullness and leaking of urine for 10 years, which is progressively getting worse. She is a G4P4 and is postmenopausal. Nothing seems to improve her symptoms, and coughing or running makes them worse. On physical exam her vitals are as follows: Ht 5'4", Wt 135 lb, T 98°F, BP 130/72. Her abdomen is soft and non-tender with no masses, and her pelvic exam reveals the anterior wall to be at the level of the hymen. In addition, UA dip is negative. She is on no medication. What would the most appropriate initial management include?

The Correct Answer is: A This is a stage 2 cystocele by the Baden Walker System, with urinary incontinence. It is best treated with conservative measures. If they fail, then surgery should be considered.

A 26-year-old athlete presents complaining of scant menses x 4 months. She is a G0P0, menarche was at age 13, and her menses have been mostly regular. She is a non-smoker and non-drinker, and has been trying to achieve pregnancy x 8 months. Physical exam reveals a thin, white female in no distress. Vitals are normal, BMI is 17.5, her pelvic exam is normal, and STD cultures are negative. A pregnancy test is negative in clinic. What is the most likely cause for her amenorrhea?

The Correct Answer is: B A young healthy woman with a low BMI, no other signs of virilization, and a history of normal menarche is most likely to have induced amenorrhea, due to suppression of the hypothalamic axis from low weight and fat index.

A 29-year-old G3P2 presents to the office for her obstetrical visit. She is currently 16 weeks gestation by ultrasound. Her pregnancy has had no complications to date. She is a non-smoker and takes her prenatal vitamin. What routine obstetric lab should be offered at this visit?

The Correct Answer is: B AFP testing is only available between 15 and 20 weeks gestation. HIV is done on initial visit and amniocentesis is offered for risk factors, advanced age, or abnormal AFP

A 24-year-old female, with a history of type 2 diabetes, presents with the inability to conceive after 14 months of unprotected sexual intercourse with her husband. Her vital signs are unremarkable and you calculate a BMI of 31. Physical examination reveals acne vulgaris and hirsutism. Which of the following treatment options for her infertility would be the most effective considering your suspected diagnosis?

The Correct Answer is: B Clomiphene citrate is highly effective as the first line treatment for infertility in PCOS.

A 27-year-old woman complains of years of menstrual irregularity and increasing facial and chest hair. PMH: significant for ovarian cyst and left cytectomy. She is a non-smoker and non-drinker. Labs include a negative uCG, elevated LH, and low FSH. She desires fertility and she has not responded to three cycles of clomiphene. What would be the next choice of medication that may return ovulation?

The Correct Answer is: B Dexamethasone, finasteride, and spironalactone all treat symptoms of hirsutism, but do not treat the underlying cause of PCO or improve fertility outcomes. PCO has an underlying insulin resistance that can be treated with oral hypoglycemics and improve sensitivity to insulin.

A 23-year-old complains of chronic pelvic pain. It is worse with intercourse, several days before her period, and throughout her period. She is a GOPO, LMP two weeks ago. She is married and has had one partner for the last three years. Her symptoms have been increasing over the last year. What would the most appropriate initial management of her symptoms include? A Expectant management B Combined oral contraceptives C Surgical intervention D Acetaminophen E Androgen therapy

The Correct Answer is: B Endometriosis treatment is aimed at reducing pain and preserving fertility. Surgical interventional is not first line therapy until medication has been tried. NSAIDS are used, as opposed to acetaminophen, to lower the prostaglandin levels. Combined oral contraceptives suppress ovulation, decrease menstrual flow, and decidualize implants.

A 19 year old female presents for her first pelvic examination and is noted to have a palpable, non-tender right ovary. She is sexually active, and uses condoms for birth control and protection from STDs. Her LMP was 20 days ago. She underwent transvaginal ultrasound and was found to have a 3-cm follicular cyst. What does this right ovarian mass represent? A Retained hemorrhagic products B Intrafollicular fluids C Solid intracellular material D Germ cell layers E Keratinized squamous epithelium

The Correct Answer is: B Follicular cysts occur prior to ovulation and cause expansion of the follicular antrum, serious fluid collection, and subsequent follicular cyst formation. Corpus luteum cysts form after ovulation and may accumulate blood products. Germ cell layers and keratinized squamous epithelium are solid components of teratomas.

A 24-year-old delivers twins by cesarean section. The twins are monozygotic. The placenta was fused. What does this implies? A Single ovum and single chorion B Single ovum and double chorion C Double ovum and single chorion D Double ovum and double chorion E Triple chorion

The Correct Answer is: B Identical twins indicate single ovum. If the placenta is fused or double it means there are two chorions, and that the trophoblast differentiation occurred before day 3.

A 37-year-old female presents to the labor and delivery department complaining of intermittent pain and contractions. Upon arrival, she also complains of vaginal bleeding. She is a G3P2 at 39 weeks gestation; no other prenatal complications are noted. She is a non-smoker. A physical exam reveals the following: P 90, BP 130/80, T 98.7°F, abdomen gravid, positive bowel sounds, and left lower quadrant tenderness noted. A sterile speculum exam reveals the cervix to be dilated 8, fetus is cephalic, and membranes are intact. The fetal monitor reveals heart tones in the 140s with mild, decreased variability and good quality contractions noted. Delivery is felt to be imminent, and vaginal delivery has been determined to be the best course of action. What will likely decrease bleeding and shorten time to delivery? A Increased activity level B Amniotomy C Oxytocin therapy D Epidural placement E IV sedation

The Correct Answer is: B If the fetus is mature and vaginal delivery (versus c-section) has been determined to be the best course of action, then amniotomy may diminished amnionic fluid volume. This might also allow for better spiral artery compression, and serve to both decrease bleeding from the implantation site and reduce entry of thromboplastin into the maternal circulation.

A 30-year-old woman delivers a viable 7 pound 6 ounce female infant by normal spontaneous vaginal delivery. The infant was delivered and held below the introitus. The infant was dried, stimulated, and apgars were assigned. The cord was then clamped and the infant was placed on the maternal abdomen. Which of the following is a complication that can arise from this? A Hypovolemia B Hyperbilirubinemia C Hypoglycemia D Hyperglycemia E Hypoxia

The Correct Answer is: B In a normal delivery, after the infant is delivered through the introitus it should not be held below it; excessive fluids can be passed to the infant, resulting in increased hematocrit and hemoglobin, which will hemolyze and cause hyperbilirubinemia.

How many types of primary osteoporosis are there?

The Correct Answer is: B Osteoporosis is a condition characterized by low bone mass, which increases the fragility of bones and leads to an increased risk of fracture. Osteoporosis is defined as being either primary or secondary and primary osteoporosis is further broken down into Type 1 and Type 2. Type 1 is related to decreased hormone levels - estrogen in women and testosterone in men, and is sometimes referred to as "postmenopausal osteoporosis." It is six times more common in women and results in loss of trabecular bone. Type 1 primary osteoporosis often presents with vertebral compression fractures or fractures of the distal radius after a fall. Type 2 primary osteoporosis is sometimes referred to as "senile osteoporosis" and generally occurs in patients over 70 years of age. It is twice as common in women as men and occurs due to a diminished capacity to make new bone. The most common types of fractures found in this type of osteoarthritis are hip and pelvic fractures. Secondary osteoporosis occurs at a somewhat higher rate in men versus women and is caused by some other medical condition that produces bone loss. Common causes include long-term steroid use, various endocrine abnormalities, and neoplastic diseases such as multiple myeloma.

A 25-year-old female presents for an ultrasound after having a positive home pregnancy test. She has an unremarkable past medical history and physical exam. She states she has been feeling fine without any abdominal discomfort or vaginal bleeding noted. On ultrasound you determine she is 10 weeks pregnant. You note a noncomplex unilateral mass on her left ovary measuring 2 cm in diameter. Which additional history would support your suspected diagnosis? A History of herpes simplex virus B She used clomiphene to conceive C Two previous Caesarian sections D 20-pound unintentional weight loss E Previous miscarriage at 7 weeks gestation

The Correct Answer is: B Patients who used assisted reproduction, such as clomiphene, present a special subgroup as their ovaries frequently have ovarian cysts. This is common during the first trimester due to ovarian hyperstimulation.

A 28-year-old G1P0 at 37.5 weeks gestation complains of a thin, watery discharge for the last 5 hours. She has soaked 3 pads. She has no pain and the fetus continues to be active. An external fetal monitor reveals heart tones in the 140s, with variability and no contractions. The pH of the vaginal fluids is 8. What does this indicate? A Normal vaginal secretions B Amniotic fluid C Yeast vaginitis D Bacterial vaginitis E Urine

The Correct Answer is: B Premature rupture of membranes is the rupture of membranes before the onset of labor (within 2 hours); preterm rupture is the rupture prior to 37 weeks gestation. The absence of contraction on the monitor, in addition to no complaints indicates no labor. Urinary incontinence is common, but the ph of 8 indicates amniotic fluid.

A 23-year-old woman presents to clinic complaining of amenorrhea for 3 months. She also complains of increasing facial hair and weight gain. On exam, PMH: menarche age 13. Physical exam reveals a well-developed, slightly obese female with a BMI of 29. Her amenorrhea can likely be improved with which therapy?

The Correct Answer is: B Progesterone administration slows GnRH pulses, thereby improving FSH secretion and follicular maturation.

You are taking care of a 32-year-old G2P1 at 39 weeks gestation in active labor. Her pregnancy is complicated by gestation diabetes. The fetal head delivered, but the anterior shoulder did not deliver with gentle downward traction. What would be the next most appropriate action? A More forceful traction and fundal pressure B Call for assistance and McRoberts maneuver C Call for assistance and more forceful traction D Call for help and fundal pressure

The Correct Answer is: B Shoulder dystocia is an obstetrical emergency, and help should always be summoned. The McRoberts maneuver increased the AP diameter, thus accommodating a large head; subrapubic pressure can help dislodge the anterior shoulder, but simple fundal pressure continues to impact it against the pelvic bone.

Which bone is the most susceptible and most often fractured at birth?

The Correct Answer is: B The clavicle is the most common bone broken during childbirth.

A 22-year-old female present complaining of a lump in her left breast. She noticed it two days ago while taking a shower. She is a non-smoker and has three to four drinks per week. PMH is negative and FMH is negative. On physical exam, vitals are normal, and a breast exam reveals a 1-cm discrete, soft, and rubbery lesion in the upper outer quadrant—it is non-tender, and the remainder of the breast exam is normal. What is the most likely diagnosis?

The Correct Answer is: B The most common mass in premenopausal women by far is a fibroadenoma. While any lesion needs to be followed, soft, mobile, non-tender, and small lesions in young women without family history are very characteristic of fibroadenoma.

You are monitoring a 30-year-old G2P1 at 40 weeks gestation, who is in an active stage of labor and is 6-cm dilated. The fetal heart tracing has a baseline heart rate of 140, with 7 to 10 beats of variability. With the last five contractions you have noted late decelerations. What would be the next most appropriate course of action? A Close observation of FHR tracing B Assessment of dilatation C Augment contractions with oxytocin D Intravenous analgesic E Surgical intervention

The Correct Answer is: B The presence of recurrent late decelerations should raise the suspicion for fetal distress. Vaginal evaluation for change in dilatation or cord prolapse, and to assess the fetal response to stimulation, are the first steps in evaluating the need for intervention.

A 29-year-old G2 P1 who is term requests induction. Her pregnancy has been uncomplicated. She has been bothered by significant, poor quality contractions, which have caused her pain and interfered with her sleep. An elective induction is considered safe when the Bishops score is greater than what number?

The Correct Answer is: C A Bishop score greater than 9 is considered a positive predictor for safe delivery in a term pregnancy.

A 37-year-old woman who takes no medication and is otherwise healthy has developed a spontaneous "bloody discharge" from her left breast. Examination reveals no tenderness, masses, dimpling, or asymmetry. Gentle pressure at the margin of the areola reveals single duct involvement. This most likely represents which of the following? A Fibroadenoma B Fibrocystic changes C Intraductal papilloma D Malignancy E Pituitary adenoma

The Correct Answer is: C A unilateral serous or serosanguinous nipple discharge from a single duct is more likely a benign intraductal papilloma A less-likely intraductal malignancy (D), however, is possible and must be ruled out. Fibroadenomas (A) and fibrocystic changes (B) are not usually associated with nipple discharge.

A 30-year-old woman and her husband have been trying unsuccessfully to become pregnant for the past year. Over-the-counter ovulation tests have indicated that she is ovulating. As part of her evaluation she undergoes a hysterosalpingogram that reveals tubal scarring. Which of the following is the most likely explanation for this finding? A Congenital anomaly of the tubes B Diethylstilbestrol exposure C Past asymptomatic chlamydial infection D Previous abdominal surgery E Scarring from prior uterine instrumentation

The Correct Answer is: C Chlamydial infection can cause "silent" pelvic inflammatory disease, leading to scarring with subsequent tubal obstruction that can cause infertility or ectopic pregnancy. Congenital anomalies of the tubes (A) may also contribute to infertility, but is not associated with scarring. DES exposure (B) in utero may lead to reproductive-system anomalies in offspring. Past abdominal surgery (D) may lead to adhesions that inhibit fertility. Uterine instrumentation (E) may lead to intrauterine synechiae.

A 30-year-old female G2 P2, who delivered via normal spontaneous vaginal delivery, presents complaining of increasing vaginal pressure, low back pain, and stress incontinence. What is the mostly likely cause of her condition? A Damage to the levator muscles B Increased intra abdominal pressure C Widening of the levator gap D Widening of the AP pelvis diameter E Endopelvic fascia remodeling and cervical elongation

The Correct Answer is: C Damage to the levator and increased abdominal pressure are known risk factors, but the widening of the gap with the associated risk factors is what allows the defect to occur. Fascia remodeling can occur instead of a prolapse defect.

A 25-year-old woman brings in her menstrual calendar as part of a preconceptional counseling visit. Her cycles are regular, occurring every 30 days and lasting 3-4 days. She has mild cramping on days 1 and 2 that is easily relieved by ibuprofen or acetaminophen. On what day of her cycle is she most likely ovulating?

The Correct Answer is: C Day 1 of menses is the start of a new menstrual cycle. In normally menstruating women, the luteal phase is stable at 14 days, i.e., ovulation ordinarily occurs 14 days before the onset of the next menses. Therefore, in a woman with a very regular 30-day cycle it is most likely to occur on day 16

A women is being evaluated at her 36-week obstetrical appointment. She is not obese, her bladder is empty, and she does not have any complications. The fetus is in a cephalic position by Leopold maneuver. You measure her fundal height. What should it measure? A 32 to 34 cm B 32 to 36 cm C 34 to 38 cm D 35 to 39 cm E 32 to 39 cm

The Correct Answer is: C Fundal height in an uncomplicated, normal weight pregnancy should be within 1 to 2 cm per week of gestation in pregnancies above 20 weeks.

A 22-year-old female presents to her obstetrical appointment at 39 weeks gestation. Her pregnancy to date has been uncomplicated. She is concerned that her infant may be larger than average, as her fundal height measures 41. On physical exam, her fetus is in a cephalic presentation, her cervix is soft and 1-cm dilated, and the fetus is at a -3 station. Her membranes are intact, she is not contracting, and her vitals are normal. She requests to be induced. For decreased risk of complication and optimal fetal outcome, when should she expect to be induced?

The Correct Answer is: C In the absence of complication, the recommendation from ACOG is to wait for labor to occur. Large for gestational age is not an indication for induction in the absence of diabetes. Gestations greater than 42 weeks increase risk of fetal stillbirth.

A 27-year-old woman and her male partner come to the emergency department for assistance with emergency contraception. They experienced condom failure during intercourse an hour ago and neither desires pregnancy. Her last menstrual period was approximately two weeks ago and her cycles occur every 28-30 days. Her medical history includes a deep venous thrombosis during labor and delivery 5 years ago. What is the most appropriate course of action at this time? A Administration of an ethinyl estradiol and levonorgestrel combination now and in 12 hours B Dilation and curettage C Insertion of a copper-containing intrauterine device D Serial beta hCG determinations E Testing for factor V Leiden

The Correct Answer is: C Insertion of a copper-containing IUD is an effective means of preventing an unintended pregnancy in this case.

A 25-year-old female presents for an ultrasound after having a positive home pregnancy test. She has an unremarkable past medical history and physical exam. She states she has been feeling fine without any abdominal discomfort or vaginal bleeding noted. On ultrasound you determine she is 10 weeks pregnant. You note a noncomplex unilateral mass on her left ovary measuring 2 cm in diameter. What is the most likely diagnosis? A Benign cystic teratoma B Serous cystadenoma C Functional ovarian cyst D Hemorrhagic ovarian cyst E Torsion of the adnexa

The Correct Answer is: C More than 90% of unilateral, noncomplex masses that are measured to be less than 5 centimeters in diameter that are identified in the first trimester are functional ovarian cysts. Benign cystic teratomas (A) make up 21% of pathologic ovarian neoplasms and serous cystadenomas (B) make up 21%. A hemorrhagic cyst (D) is a non-functional cyst. Torsion of the adnexa (E) is most commonly seen between 6-14 weeks gestation or in immediate puerperium but symptoms include abdominal pain and tenderness.

A 20-year-old woman was just told by her new sexual partner that she needed to be checked for a sexually transmitted infection because he has developed dysuria and a profuse urethral discharge. She herself has had a subjective fever for the past two days, some nausea but no vomiting, diffuse lower abdominal pain, and a severe backache. On examination, she has a temperature of 100.5˚F, hypoactive bowel sounds, bilateral lower abdominal quadrant tenderness, a profuse mucopurulent cervical discharge and pronounced cervical motion tenderness. Serum pregnancy testing is negative. She is given an injection of ceftriaxone and a prescription for doxycycline for 14 days and an appointment for follow up the next day. Under which of the following conditions should metronidazole be added to her regimen?

The Correct Answer is: C Recommended regimens for treatment of pelvic inflammatory disease include ceftriaxone or another parenteral third-generation cephalosporin and doxycycline or cefoxitin, probenecid, and doxycycline. Metronidazole (or clindamycin) should be added to either regimen if a tubo-ovarian abscess is present.

A 19-year-old G1P0 presents for her routine obstetric exam. She is at 34 weeks gestation. When completing the physical assessment you perform a Leopold maneuver. What does this maneuver assess? A Fetal lie and station B Fetal position and presentation C Fetal lie and position D Fetal lie and presentation E Fetal position and station

The Correct Answer is: C The maneuver is used to examine the abdomen and determine the lie (first) and position (second).

A 46 year-old female has just been diagnosed with ovarian cancer. Where would you expect the ovarian neoplasm to most likely arise from? A Germ cell B Stromal cell C Epithelial cell D A Metastatic tumor E Endometrial cell

The Correct Answer is: C The most common and most lethal of the ovarian neoplasms arise from the ovarian epithelium found both on the surface of the ovary and in subsurface locations

You are caring for a pregnant woman who is Rh-negative. The father of the child is Rh-positive and heterozygous. What percent chance will the fetus have of being Rh-positive?

The Correct Answer is: C The mother is negative and has no genetically positive material to pass to the child; the father is heterozygous, so only half of his genetics contain the positive antigens.

At her routine annual pelvic exam, a 39-year-old female presents to the clinic complaining of pelvic pressure and bloating for several months. She is a G3P2 who delivered vaginally. She is a nonsmoker. Her maternal aunt had a history of ovarian cancer. Her pelvic exam reveals an 8-cm ovarian mass in the right adnexal area. What is the most appropriate evaluation of the ovarian mass?

The Correct Answer is: C The patient is high risk, as she is premenopausal, has a family history of cancer, and the mass is large. Therefore, surgical evaluation should be undertaken. CA 125 can be negative in early disease, and pelvic US and CT are not sensitive enough. Repeat examination should be reserved for low risk women with smaller ovarian masses.

A 24-year-old G2P2 delivered a viable female infant (8 lb 4 oz) via caesarean section, after a failed 20-hour induction for post date pregnancy. On day 2, she developed a postoperative fever of 101F (38.3C). She had slightly increasing abdominal cramping and pain, no change in loci, is voiding well, and has passed flatulence. Her WBC is 19,000. What is the mostly likely cause for her fever? A Urinary tract infection B Ileus C Metritis D Atelectasis E Tubo-ovarian abscess

The Correct Answer is: C The patient is passing urine and flatulence well, making choices A and B less likely. Fever greater the 38C is the most important indicator of metritis. Fever is not usually indicative of mild atelectasis. Tubo-ovarian abscess is usually a complication from PID. The patient has many risk factors for metritis including c-sect, prolonged induction, and fever

A 51-year-old female presents to her primary care provider for her annual physical. She is a healthy white female and a non-smoker. She has mild HTN, but an otherwise negative health Hx. In addition, FHx is negative and ROS is negative. Her LMP was 6 months ago. Her last mammogram was 3 years ago. When should she have her next mammogram? A In 2 years B In 1 year C Now D Only if self breast exam reveals abnormality E Only if provider breast exam reveals abnormality

The Correct Answer is: C The preponderance of data strongly supports the benefits of a screening mammography. New analyses of older randomized studies have suggested that screening may not work. While the design defects in some older studies cannot be retrospectively corrected, most experts, including panels of the American Society of Clinical Oncology and the American Cancer Society, continue to believe that screening conveys substantial benefit.

A women presents to the labor department complaining of contraction every 3 to 4 minutes for the last 3 hours. She is a G1P0 at 40 weeks gestation. Her pregnancy is uncomplicated; her group B strep culture is negative. Physical exam vitals are normal, the baby is cephalic in a +2 station, and the bag of water is intact. The fetal heart monitor reveals fetal heart tones in the 140s with contractions every 3 minutes lasting 45 seconds. Her cervix is 4-cm dilated and 50% effaced. What is the expected rate of cervical dilation?

The Correct Answer is: C This patient is in stage one active labor and is a primigravida. She should expect 1.2 cm of dilatation per hour; multigravida women can expect a faster rate of dilatation.

A 24-year-old gravid 3 para 0 ab 2 presents complaining of vaginal pressure every 2 hours, but no pain. She is at 26 weeks gestation. This pregnancy is uncomplicated to date. On physical exam she is in no acute distress and her vitals are normal. She is placed on a fetal monitor and no contractions are noted; fetal heart tones are 138. A sterile speculum exam reveals her cervix to be dilated to 4 cm. What is the most likely diagnosis? A Preterm labor B Group B Streptococcus C Incompetent cervix D Braxton Hicks contraction E Chlamydia trachomatis

The Correct Answer is: C While infection is a significant cause of premature labor, it is not a cause of incompetent cervix. Incompetent cervix is most likely found in the presence of recurrent pregnancy loss and painless dilatation.

A 60-year-old postmenopausal woman who has had negative annual Papanicolaou smears of the cervix for many decades reports that her husband has been in a nursing home for almost a year and that she is no longer sexually active. He was her only sexual partner. She has no personal or family history of cancer and has never taken or been exposed to any kind of hormone. She asks if she really needs to continue having testing every year. What is the correct advice for her?

The Correct Answer is: C Women between the ages of 30 and 64 who have had 3 consecutive negative Pap smears and no additional risk factors may reduce the frequency of their screenings to every 2-3 years.

A 40-year-old female is status post a dilatation and curettage for hydatidiform mole. On week 3 post surgery, her follow-up quantitative hCG level has elevated slightly. What is the most likely diagnosis? A Adenocarcinoma of the ovary B Adenocarcinoma of the uterus C Retained hydatidiform mole D Choriocarcinoma E Corpus luteum cyst

The Correct Answer is: D 5% of hydatidiform mole progress to choriocarcinoma; the longer the mole in intrauterine the higher the risk. Pre-surgical evaluation for mole removal includes a chest x-ray to rule out distant metastasis. hCg that either plateuas or elevates is choriocarcinoma until proven otherwise, and requires prompt evaluation.

A 65-year-old female presents to clinic for her annual pap smear. She is in good health but has mild hyperlipidemia, which is controlled with diet. She had a hysterectomy more than 10 years ago for dysfunctional uterine bleeding. How often should she have a pap smear? A Annually B Every 2 years C Every 3 years D Symptomatically

The Correct Answer is: D According to the new 2010 ACOG guidelines, women who have no high-grade lesions or cervical cancer history, and are over 65, may discontinue cervical cancer screening due to the decrease risk and slow progression if disease does occur.

A 19-year-old presents to clinic requesting emergency contraception. She is a G1P0Ab1 and a non smoker who has had intercourse and the condom broke. Her LMP was 3 weeks ago. Her PMH is negative. What would be the time frame for maximum efficacy for her to use emergency contraception?

The Correct Answer is: D Emergency contraception, both hormonal and IUD, reduces pregnancy rates for 120 hours, but there is a significant decrease in efficacy after 72 hours.

A progestin-only contraceptive, or "minipill," would be most appropriate for which of the following patients? A a 25-year-old woman in excellent overall health B a 28-year-old woman with a history of epilepsy C a 32-year-old woman with a history of pelvic inflammatory disease D a 37-year-old woman who smokes 2 packs per day and has a history of hypertension E a 38-year-old woman with a history of asthma and bronchitis

The Correct Answer is: D In the majority of cases, a combined hormonal contraceptive (ie, one that contains both an estrogen and progestin) is the preferred method of oral contraception because of its efficacy when used perfectly (>99%). However, for women older than 35 years of age who are smokers or are obese, or who have a history of hypertension or vascular disease, progesterone-only contraceptives are recommended. Ethinyl estradiol (EE), the most common estrogen found in combined hormonal contraceptives, has been associated with an increased risk of myocardial infarction in women older than 35 years of age who are smokers. Additionally, EE has also been shown to cause increases in blood pressure in both normotensive and mildly hypertensive women.

A 35-year-old nulliparous female has had increasing and heavy flow with her menstrual cycles over the last six months. She is being followed by her gynecologist, who has diagnosed several small uterine fibroids. She presents in clinic today with complaints of tachypnea on exertion, tachycardia, and occasional palpitations. There is no family history of cardiac problems or hypertension. She denies symptoms of infectious etiology and has no fever. On physical examination, you note a mild tachycardia of 110 after she has been sitting for a few minutes. No other physical findings are noted. What would be the next most useful diagnostic study to help you confirm the diagnosis?

The Correct Answer is: D Iron deficiency develops in stages. The first is depletion of iron stores. There is no anemia or change in RBC. The serum ferritin will become abnormally low and lead to symptoms of anemia, such as easy fatigability, tachycardia, palpitations, and tachypnea on exertion. Iron deficiency anemia is more frequently seen in women, especially those with heavy menstrual cycles, as they are unable to absorb enough iron in their diet to maintain stores—leading to depletion, signs of anemia, and progression if not treated.

A 53-year-old woman presents to clinic complaining of amenorrhea, irritability, and hot flashes for 6 months. She would like to try hormone replacement therapy. You are counseling her about possible risks versus benefits. Which of the following is a benefit of combined estrogen progestin therapy?

The Correct Answer is: D The WHI study showed increase chance of cardiovascular risks and breast cancer, and showed no improvement in prevention of cognitive decline

You are caring for a 29-year-old G1P0 at who is pregnant with twins. She has received routine obstetrical care and her pregnancy has been uneventful to date. What is the average gestation age for twins at delivery?

The Correct Answer is: D The average length of gestation for a single fetus is 40 weeks; the average age of gestation decreases with increasing number of fetuses D 36 to 37

An 18-year-old G1P0 presents for evaluation of her amenorrhea. Her LMP was 2 months ago. Her HCG is positive, and she has been having vaginal spotting x 2 weeks. Her ultrasound reveals an intrauterine heterogeneous echogenic mass, without fetus or placenta. What is the most likely diagnosis? A Threatened abortion B Missed abortion C Ectopic pregnancy D Hydatidiform mole E Early intrauterine pregnancy

The Correct Answer is: D The classic signs for a mole are a heterogenous mass without the placenta or fetus, and vaginal spotting is present all of the time. The presence of the mass intrauterine without fetus or placenta rules out ectopic and IUP, and therefore threatened abortion. Missed abortion is not echogenic

A 31-year-old woman is being evaluated for irregular, infrequent menstrual periods. On further questioning, she complains of headaches, fatigue, and breast discharge. She takes ibuprofen only occasionally. Which of the following labs would most likely be elevated in this patient? A BUN and creatinine B luteinizing hormone (LH) and follicle-stimulating hormone (FSH) C oxytocin D prolactin E TSH

The Correct Answer is: D This patient's symptoms are consistent with a pituitary adenoma. Prolactinomas account for about half of all functioning pituitary tumors and may secrete PRL, GH, and ACTH.

A 30-year-old woman comes in for evaluation of infertility. She and her husband have been having unprotected intercourse for the past year. Her menstrual cramps have become increasingly painful, and she has a severe low backache for several days before and during her menses. She complains that intercourse is painful when her husband "goes deep." Physical examination reveals multiple tender nodules of various sizes in the posterior vaginal fornix. Definitive diagnosis is best accomplished using what methodology? A Abdominal radiography B CA-125 measurement C CT scanning of the abdomen D Laparoscopy E Pelvic ultrasonography

The Correct Answer is: D This woman has a classic presentation for endometriosis. Definitive or final diagnosis can only be made at laparoscopy or laparotomy, allowing direct visualization of the endometrial implants.

You are providing care for a 21-year-old G1P1 who delivered a 3990 gram infant by normal spontaneous vaginal delivery. After delivery, she continues to bleed vaginally, more than is expected for routine delivery. What is the most likely cause of her hemorrhage? A cervical laceration B lateral vaginal wall laceration C retained placenta D uterine atony E placenta acreata

The Correct Answer is: D Uterine atony continues to be the most common cause of postpartum hemorrhage, even though all of the answer choices may cause it.

A 47-year-old female presents to the office complaining of excessive menstrual flow for the past two months. She complains of mid-cycle bleeding, as well as periods that last for nine days. What is the mostly likely cause of her bleeding?

The Correct Answer is: D While all are causes for abnormal bleeding, anovulotory bleeding occurs in perimenopausal women due to the unopposed estrogen. STD and pregnancy would be more likely during reproductive years. Neoplasms accounts for approximately 20% of abnormal uterine bleeding in the post reproductive years.

A 48-year-old woman presents complaining of vaginal fullness and difficulty passing stool. Upon exam she is found to have a stage 3 rectocele by the Baden Walker System. What is the most common cause for this? A Increasing age B Genetic disposition C Obesity D Pelvic floor injury E Constipation

The Correct Answer is: D While all of the answer choices are risk factors, the most common cause of pelvic organ prolapse remains pelvic floor injury, usually related to child birth or trauma.

You are caring for a 29-year-old G3P2 at 39 weeks gestation, who has been laboring for 6 hours. She is a diet-controlled diabetic. Her last child was 9 pounds 8 ounces. She has been completely dilated for 2 hours, and the fetal head is at a plus 2 station, which is unchanged. What is the next most appropriate course of action? A Begin oxytocin B Vacuum extraction C High forcep extraction D High forcep rotation E Cesarean section

The Correct Answer is: E The patient is a diabetic with a history of a macrosomic infant; the likelihood of macrosomia in this infant is significant. Instrument delivery is not recommended if macrosomia is suspected. By definition, she has had an arrest of descent of the fetal head and one should be highly suspicious for macrosomia, in which case a c-section is the preferred method of delivery

A 35-year-old female presents to discuss non-permanent methods of birth control. She is a G3P2, PMH negative. She is a smoker. Which method of contraception would have the lowest risk profile for her? A Combination low dose pill daily B Injectable progestin monthly C Transdermal combination patch D Levonorgestrel intrauterine device E Copper intrauterine device

The Correct Answer is: E A women who is over 35 and smokes is at high risk for cardiovascular complications. All choices except the copper IUD contain hormones, which may increase the risk of complications. The copper IUD is long term but non-permanent.

During her active phase of labor, a provider has placed an external fetal monitor on a patient. The fetal heart rate (FHR) is noted to have a base line rate of 109, there are no late or variable decelerations, and the baseline variability is 0 beats per minute. What is this monitor tracing indicative of? A A normal FHR pattern B An indeterminate FHR pattern C An unreadable FHR pattern D Poor contact with monitor E A distress FHR pattern

The Correct Answer is: E According to the Three-Tier Fetal Heart Interpretation System, recommended by the 2008 NICHD workshop on electronic fetal monitoring, the definition of fetal distress includes absence of baseline variability, and either bradycardia (FHR<110) or recurrent variable or late decelerations.

A 37-year-old female presents to the office complaining of increasing heavy vaginal bleeding with her menses. CBC reveals an iron deficient anemia. Her pelvic exam is notable for a moderately enlarged uterus. A transvaginal ultrasound reveals a 3-cm leiomyoma and a 15-cm leiomyoma. The patient wishes to preserve her fertility. Appropriate management would include which of the following? A Expectant management aimed at pain reduction B Bilateral uterine artery embolization C Reduction of blood loss with combined oral contraceptives D Immediate hysterectomy E Gonadotropin-releasing hormone analog followed by myomectomy

The Correct Answer is: E GRH causes a reversible hypogonadism, which reduces tumor size, makes surgical intervention safer, and reduces bleeding. The patient wishes to preserve her fertility, making embolization and hysterectomy non-viable options. COC do not significantly reduce bleeding, and do not regress the tumor for optimal surgical removal.

A 30-year-old woman presents to the office complaining of an inability to achieve pregnancy after over a year of trying. What is the couple's least likely cause for infertility? A Azoospermia B Ovarian failure C Endometrial disease D Tubal disease E Pituitary disease

The Correct Answer is: E In the vast majority of women who are infertile or subfertile, the issue is due to either ovarian dysfunction or structural abnormalities, with hormonal abnormalities accounting for only 10%.

A 29-year-old woman comes to the emergency department with abrupt onset of left lower quadrant pain approximately 1.5 hours ago after she and her roommate moved multiple heavy pieces of furniture into their new apartment. The pain is now excruciating and she rates it "100 out of 10." She vomits on admission to the department. She is not currently sexually active and has no other significant past medical history. On exam she is found to have fullness and extreme tenderness in the left adnexa. Of the following, what is the most likely diagnosis?

The Correct Answer is: E Ovarian torsion is often extremely painful and is often accompanied by vomiting, with sudden onset and may be associated with episodes of heavy exertion.

A 17-year-old female presents to the emergency department complaining of watery vaginal discharge for 6 hours. She is found to be at 35 weeks gestation. An external fetal monitor reveals fetal heart tones in the 130s, good variability, and no contractions. What is the most likely diagnosis? A Preterm labor B Preterm rupture of membranes C Premature rupture of membranes D Preterm labor and premature rupture of membranes E Preterm and premature rupture of membranes

The Correct Answer is: E Preterm rupture of membranes is defined as rupture before 37 weeks gestation; premature is defined as before the onset of labor. The absence of pain or contractions decreases the likelihood of labor.

A 25-year-old woman comes in for her annual physical examination and renewal of her oral contraceptive prescription. She has no problems today and appears fit and well. On palpation of the thyroid, the right lobe is small, smooth, and free of nodules, but appears to be slightly larger than the left lobe. She has no other unexpected physical findings. The enlargement most likely represents which of the following? A inflammation of the thyroid B goiter C hypothyroidism D malignancy E normal finding

The Correct Answer is: E Slight enlargement of one lobe of the thyroid gland in a healthy woman with no complaints is most likely a normal finding. In patients with an inflammation of the gland (A), i.e., thyroiditis, and hypothyroidism (C) the thyroid is usually diffusely enlarged and may be markedly asymmetric. Other findings depend upon the cause. Goiters (B) are typically nodular and may be quite enlarged. Thyroid malignancy (D) usually presents as a firm, non-tender nodule.

A G4P4 woman delivers a viable infant at 38 weeks gestation by normal spontaneous vaginal delivery. The infant has apgars of 7 and 8 (at 1 and 5 minutes respectively). What is the most crucial time for maternal and fetal physiologic changes to occur?

The Correct Answer is: E The hour after birth is the most critical time for physiologic changes to occur, including maternal fluid shifts, hemorrhage, retained placenta, and fetal lung cardiovascular transitions

A 30-year-old G1P0 woman who is 15 weeks pregnant undergoes "triple screening." The maternal alphafetoprotein (AFP), human chorionic gonadotropin (hCG), and unconjugated estriol (uE3) levels are all lower than normal. This suggests which of the following possible problems with the fetus? A cystic fibrosis B Down syndrome C homocystinuria D G6PD deficiency E trisomy 18

The Correct Answer is: E The triple screen detects possible Down syndrome and trisomy 18. When the fetus has Down syndrome (B), the AFP and uE3 are low and the hCG is high, while trisomy 18 is suggested by low values in all three. A positive screen must be followed up by fetal karyotyping. Cystic fibrosis (A), homocystinuria (C), and G6PD deficiency (D) are not detected by the triple screen.

A 25-year-old gravida 1 woman who is HIV positive arrives at the hospital in early labor. Membranes are intact and the cervix is 50% effaced and 3 to 4 cm dilated. Fetal heart rate is 150 beats/min. Which of the following procedures is contraindicated during labor? A amniotomy B augmentation of labor with oxytocin C external monitoring D operative delivery E use of fetal scalp electrodes

The Correct Answer is: E Use of fetal scalp electrodes and scalp sampling is contraindicated in the HIV-positive woman because it increases the risk of vertical transmission of the human immunodeficiency virus to the infant. While ruptured membranes for more than 4 hours is associated with an increased risk of vertical transmission, amniotomy per se is not contraindicated

A 34-year-old diabetic female complains of amenorrhea for the past 2 months. Last week she tested positive for strep pharyngitis and is currently being treated. She admits that she has not been using birth control. Her urine HCG is positive. Her current medications are listed in the choices below. Which of the following medications should you discontinue? A amoxicillin B lisinopril C acetaminophen D humalog insulin E methyldopa

The correct answer is (B). Lisinopril, an ACE inhibitor, is contraindicated in pregnancy due to known problems with fetal toxicity and should be stopped as soon as possible once pregnancy is confirmed.

A 30-year-old patient presents to labor and delivery complaining of bright red vaginal bleeding. She has no pain. The fetus is still active. She is 37 weeks pregnant. PMH is significant for in vitro fertilization. What is the most likely diagnosis? A Placental abruption B Placenta acreata C Placenta previa D Disseminated intravascular coagulopathy E Active labor

he Correct Answer is: C The most likely diagnosis is placenta previa, as the bleeding is bright red and painless.

A 25-year-old woman and her husband have been using condoms and spermicidal foam for the 8 months since the birth of their baby. She plans to wean the baby from the breast sometime between a year and 18 months of age, but would like to begin a "less messy" method of contraception. Prior to her pregnancy she took combination oral contraceptives for several years without any difficulties. Which of the following is an appropriate recommendation for this woman?

he Correct Answer is: C The progestin-only pill is ideal for breast feeding mothers because this pill does not interfere with lactation the way combination pills do

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