OBGYN Shelf

How to manage a fetal demise?

- 20-23 weeks: dilation and evacuation OR vaginal delivery - 24+ weeks: vaginal delivery - but don't wait for spontaneous delivery - you induce it in the hospital

What amount is considered adequate for maternal contractions?

- 200 Montevideo units/10 minutes

Preterm labor: how to manage each one: - 34 0/7 - 36 6/7 - 32 0/7 - 33 6/7 - <32

- 34 0/7 - 36 6/7: plus or minus betamethasone, penicillin if GBS positive or unknown - 32 0/7-33 6/7: betamethasone, tocolytics (indomethacin is first line) and pencillin if GBS positive or unknown - < 32 weeks: betamethasone, tocolytics, penicillin if GBS positive or unknown and magnesium sulfate (neuroprotection)

Bilateral labial masses think of?

- 5-alpha reductase deficiency

What is a normal post void residual volume?

- 50-60 cc - An elevated one indicates overflow incontinence

Define active phase protraction (labor) and the most common cause.

- <1 cm/2 hours during the active phase (6 cm- 10 cm) - Most commonly caused by cephalopelvic disproportion

What is considered a short, interpregnancy interval and what are the complications from it?

- <6-18 months between delivery and the next pregnancy - Complications: maternal anemia, PPROM, preterm delivery, low birth weight

What is the biggest risk factor for preterm delivery?

- A history of previous preterm delivery

Cord prolapse is associated with what?

- Abnormal fetal presentation

6 main contraindications to breastfeeding?

- Active untreated tuberculosis - HIV infection _ Herpetic breast lesions - Active varicella infection - Chemotherapy or radiation therapy - Active substance use

What is a postdural puncture headache?

- After lumbar puncture (epidural anesthesia) or neuraxial anesthesia - Positional - worse when upright, improves with supine - Neck stiffness, photophobia, diplopia, hearing loss, tinnitus - Typically self-limited

What is the management of CIN3?

- Age >25 and not pregnant - LEEP, cold knife conization, or cryoablation - then pap test with HPV 1 and 2 years post-procedure

First step in management of placental abruption?

- Aggressive fluid resuscitation with crystalloids

How do you treat uncomplicated mastitis?

- Antibiotics, mom can continue breastfeeding

How do you treat Bartholin duct cysts?

- Asymptomatic - don't do anything - Symptomatic: incision and drainage

Explain the findings - speculum and laboratory - and treatment for bacterial vaginosis, trichomoniasis, and candida vaginitis.

- Bacterial vaginosis: thin, off-white discharge with a fishy odor, clue cells and positive whiff test, treat with metronidazole or clindamycin - Trichomoniasis: thin, yellow-green malodorous, frothy discharge, motile trichomonads; treat with metronidazole and treat partner - Candida vaginitis: thick, cottage cheese discharge, pseduohyphae; treat with fluconazole

What is gestational thrombocytopenia?

- Benign condition that causes a mild isolated thrombocytopenia - Commonly diagnosed in 3rd trimester on CBC - Patients are usually asymptomatic and nothing needs to be done

A "soft" uterus is also called what?

- Boggy uterus (aka uterine atony)

Boggy, tender, uterus vs. firm, nontender uterus - both situations with increased menstrual bleeding?

- Boggy, tender, uterus - adenomyosis - symmetrically enlarged uterus - Nontender, firm uterus - uterine fibroids - irregularly enlarged uterus

Breastfeeding reduces the risk of what cancers?

- Breast cancer, ovarian cancer, and endometrial cancer

Periventricular intracranial calcifications?

- CMV

What dietary item can increase pain from cystic changes in the breast?

- Caffeine

Why do women with HELLP syndrome get right upper quadrant pain?

- Can cause serious liver problems such as centrilobular necrosis, hematoma formation and thrombi in the capillary system - All of these things can cause liver swelling with distension

pH for candida, trichomoniasis and bacterial vaginosis?

- Candida: normal 3.8-4.5 - Trichomoniasis and bacterial vaginosis: >4.5

Contraindications for carboprost tromethamine vs methylergonovine?

- Carboprost: contraindicated in asthma - Methylergonovine: contraindicated in hypertension

What diseases are babies at risk for in the future if they have fetal intrauterine growth restriction?

- Cardiovascular disease - Type 2 diabetes - Chronic hypertension - Stroke - chronic obstructive lung disease - Obesity

What is hypothalamic amenorrhea?

- Caused by strenuous exercise and relative caloric deficiency - Stress fractures, amenorrhea, infertility, - Decreased bone mineral density, decreased GnRH, decreased LH/FSH, decreased estrogen

What is pseudocyesis?

- Causes patient to think they are pregnant - present with pregnancy symptoms such as breast fullness, morning sickness, and abdominal distensions - They believe that they are pregnant, but when they get tested in an office, they have negative tests and a thin endometrial stripe - Pseudocyesis likely occurs when the somatization of stress affects the HPA axis and causes early pregnancy symptoms

What are the complications of cervical conization? (4)

- Cervical stenosis - Cervical incompetence and preterm birth - Preterm premature rupture of the membranes - Second trimester pregnancy loss

What is chorionic villus sampling able to detect? (2)

- Chromosomal abnormalities (Down Syndrome) - Genetic disorders (ex. cystic fibrosis) - Is NOT able to detect neural tube defects like amniocentesis is

Risk factors for endometrial cancer? (5)

- Chronic anovulation/PCOS - Early menarche or late menopause - Obesity - Tamoxifen - Nulliparity

What is the acid-base status in pregnancy?

- Chronic respiratory alkalosis

What is acute fatty liver of pregnancy?

- Clinical features: nausea, vomiting, right upper quadrant/epigastric pain, fulminant liver failure - Elevated aminotransferases, increased bilirubin, thrombocytopenia, DIC - Immediate delivery is management

How do you manage atypical glandular cells found on a Pap smear?

- Colposcopy (for cervical problem), endocervical curettage, and endometrial biopsy (can also signal an endometrial malignancy)

Which type of molar pregnancy has higher chance of turning into a choriocarcinoma?

- Complete > incomplete

Unsafe exercise activities in pregnancy?

- Contact sports - High fall risk - downhill skiing, gymnastics, horseback riding - Scuba diving - Hot yoga

Besides lung maturity, what else can betamethasone help with in a premature infant? (2)

- Decreased risk of intracerebral hemorrhage and decreased risk of necrotizing enterocolitis

How do you treat intrahepatic cholestasis of pregnancy?

- Delivery at 37 weeks - Ursodeoxycholic acid - Antihistamines

Women with frequent recurrent episodes of vulvovaginal candidiasis should be evaluated for what?

- Diabetes

How do you manage HSV in pregnant patients?

- Does the patient have a prior HSV infection - if NO then routine prenatal care - If yes - antiviral suppression beginning at 36 weeks - If lesions/prodromal during labor - NO - vaginal delivery; YES - Cesarean delivery

Why are babies born to pre-eclamptic moms often small?

- Due to chronic uteroplacental insufficiency

Fetal ultrasound with a dilated fluid-filled stomach and dilated proximal intestinal segment; remainder of the bowel with no air or fluid. What is this and association with what?

- Duodenal atresia - Association with Down Syndrome

Pain with urination, pain with defecation, recto vaginal nodularity...think what?

- Endometriosis

Unilocular, adnexal mass with homogenous, low level echoes?

- Endometriosis - This is describing a chocolate cyst

What is hyperthecosis?

- Essentially the most severe form of PCOS - Everything just more amplified than in PCOS

What is the most effective treatment for menopausal hot flashes?

- Estrogen in the lowest dose for the shortest duration of time possible

With patients who have risk factors for diabetes, when do you screen?

- Everyone gets the 50 g glucose test at 24-28 weeks - For people who are higher risk (obesity, etc.), you can screen with a 50 g test at their first visit regardless of GA

In a patient wtih a baby who is breech but has no other risk factors and wants a vaginal delivery, what do you do before you suggest a Cesarean delivery?

- External cephalic version - Fetus is manually rotated to cephalic presentation

What are 3 risk factors for PMS?

- Family history of PMS - Obesity - Poor diet

Risk factors for shoulder dystocia

- Fetal macrosomnia - Maternal obesity - Excessive pregnancy weight gain - Gestational diabetes - Post-term pregnancy

If the fetal heart rate can not be confirmed using external methods, what method should you use?

- Fetal scalp electrode

What is the most accurate method for determining gestational age?

- First trimester ultrasound with crown-rump length measurement

What is the treatment for infertility in patients with PCOS?

- First-line: weight loss - Second line: clomiphene citrate

What is the most common cause of first-trimester spotaneous abortion?

- Genetic/chromosomal abnormalities in the fetus

Mom has asymptomatic GBS bacteruria during pregnancy. Goes into labor at 37 weeks. Additional management?

- Give intrapartum antibiotic prophylaxis - Ampicillin/penicillin

How do you manage a newborn born to a mom with HIV? (even if the HIV was well-controlled during pregnancy)

- Give zidovudine (AZT) immediately following delivery

Treatment for gonorrhea and chylamydia?

- Gonorrhea: azithromycin + ceftriaxone - Chlamydia: azithromycin only

What type of tumor increases estrogen levels?

- Granulosa cell tumor

What is fetal dysmaturity syndrome?

- Happens in about 10% of babies with a gestational age that exceed 43 weeks - usually women who did not have good prenatal care so dates are inaccurate and baby stays in for too long - Babies have long, thin bodies, peeling skin with a green-yellow tint (meconium stained), very long finger nails and small placentas

A 34 year old woman, G1P1, comes to the office for infertility evaluation. She has been trying to conceive for the past year, but her cycles have become increasingly irregular, with the last menstrual period more than 3 months ago. Menses previously occured every 27 days and lasted 4 days. The patient feels fatigued and has been waking up at night due to feeling too warm. She has been married for 6 years and ha a 4 year old daughter who was delivered vaginally without complications. The patient has hypothyroidism for which she takes levothyroxine. She has no previous surgeries. The patient smokes a pack of cigarettes a day but does not use alcohol or drugs. Both of her parents have type 2 diabetes. BMI is 24. Vital signs are normal. Pelvic examination shows normal external genitalia, a small mobile uterus, and normal bilateral ovaries. TSH is normal and a pregnancy test is negative. What would the levels of GnRH, FSH and estrogen be?

- High GnRH, high FSH, low estrogen - She has symptoms of menopause, but she is only 34 - think primary ovarian insufficiency - Ovaries stopped working so low estrogen, and then no feedback so high everything else

What is the cause of postpartum telogen effluvium?

- High estrogen levels during pregnancy

What type of contraception can absolutely not be used in breast cancer patients?

- Hormones containing contraception

3 main side effects/risks of tamoxifen?

- Hot flashes - Venous thromboembolism - Endometrial hyperplasia and carcinoma

How to choose between hydralazine, labetalol and nifepidine for a hypertensive emergency?

- Hydralazine - usually pretty good - IV only - Labetalol - can lower pulse, so if already bradycardic, dont' use - IV only also - Nifedipine - only oral one; if they are having problems like vomiting, don't use it

Lots of fluid in baby on ultrasound of fetus, think what? Associated with what conditions?

- Hydrops fetalis - Parvovirus B19, alpha thalassemia major

Wernick encephalopathy is classically associated with thiamine deficiency from alcoholism. What pregnancy condition can also cause this?

- Hyperemesis gravidum

Infant borns to diabetic mothers at risk for what? (5)

- Hypoglycemia - Polycythemia - Hyperbilirubinemia - Hypocalcemia - Respiratory distress

How do you manage heavy bleeding caused by endometrial fibroids?

- Hysteroscopic myomectomy

How to handle a maternal request for C-section if provider does not want to do one?

- IN the absence of any inidications, the OBGYN can still do one after 39 weeks, but if they are uncomrotable doing it, they should refer patient to another provider

How do you manage a septic abortion?

- IV fluids - Broad-spectrum antibiotics - Suction curettage

Most common cause of preterm labor?

- Idiopathic

Treatment of CIN 3?

- Immediate cervical conization

What is the management of high-grade squamous intraepithelial lesions regardless of pregnancy status?

- Immediate colposcopy

34 year old woman with preterm premature rupture of membranes. Also has temperature of 103 F, pulse 11.4. On speculum examination purulent amniotic fluid emerges from the cervix. What next?

- Immediate induction of labor - With most PPROM, you can do just expectant management - However, this person has signs of an infection so you need to induce labor immediately

Blue-tinged bulge between the labia in a 12 year old who hasn't yet had menses?

- Imperforate hymen

If a breast cyst is drained and resolves with drainage, when should the patient follow-up?

- In about 2 months to ensure cyst hasn't come back/refilled

What is aromatase deficiency?

- Inability to convert androgens into estrogen - Patients have osteoporosis, undetectable estrogen levels (no breast development), and polycystic ovaries - Also high levels of testosterone, androstenedione, FSH, LH

Definition of postpartum urinary retention and the treatment.

- Inability to void 6 or more hours after vaginal delivery - Treat with ureteral catheterization

How does HRT effect HDL and LDL levels?

- Increases HDL and decreases LDL

Sheehan syndrome causes what in the pituitary gland?

- Infarction, and ischemic necrosis

Warm, red breast with dimpling. What is it?

- Inflammatory breast carcinoma

What is one of the most common side effects of fluoxetine?

- Insomnia

Unilateral bloody nipple discharge?

- Intraductal papilloma

What anti-coagulants are and are not safe during pregnancy?

- Is safe: heparin - Is not safe: warfarin

How do you manage SSRIs with breastfeeding?

- Just continue them at their normal dosees - Some of the medication gets into the breastmilk but it is a negligible amount

What nerve injury is caused by shoulder dystocia and describe it.

- Klumpke palsy - C8-T1 damaged - "Claw hand"

Two safest drugs for bipolar during pregnancy?

- Lamotrigine and levatiracetam

What is the management of an ovarian teratoma?

- Laparoscopic ovarian cystectomy to reduce the risk of ovarian torsion - Teratomas - *calcifications and hyperechoic nodules

Lichen planus vs lichen sclerosus?

- Lichen planus: desquamation and erosion of mucosal surfaces such as the vulva, vagina and oral cavity; glazed, brightly erythematous vulvar erosions with a border of serpentine-appearing white striae (wickham striae); serosanginous vaginal discharge - Lichen sclerosus: vulvar itching and white vulvar plaques; however, doesn't usually have vaginal involvement

Patinet with Myasthenia gravis admitted for severe preeclampsia. What medication is contraindicated?

- Magnesium sulfate - Can trigger a myasthenic crisis

What is the first step in management of variable decelerations?

- Maternal repositioning - Remember, variable caused by cord compression - By repositioning mom, you may be able to reduce cord compression and improve fetal-placental blood flow

Minimally rugated vagina think?

- Menopause - Of if before the age of 40, premature ovarian failure

What is false labor?

- Mild, irregular contractions without cervical change (cervix will still be closed) - Don't need to do anything is baby status is okay, just send home with labor precautions

Most common bugs for postpartum endometritis?

- Mix of aerobic and anaerobic bacteria

What is nenonatal thyrotoxicosis?

- Mom with grave's disease, low birth weight, tachycardia, warm skin, irritability - Results from transplacental passage of anti-TSH receptor antibodies during the third trimester - Can occur despite maternal treatment for Graves disease or hypothyroidism

What is the risk of pulmonary hypertension during pregnancy?

- Moms have a very high mortality risk w/ pulmonary hypertension - about 25% - They can't enough blood back to their hearts

Twin-twin transfusion syndrome is most common in what type of twins?

- Monochorionic, diamniotic

Pregnant women with UTI treated with antibiotics. Comes back two weeks later for follow-up. What do you do now?

- Need to repeat a urine culture to make sure the infection has cleared

How long is the corpeus luteum needed in pregnancy and for what purpose? What can you do if the corpus luteum gets removed before that time?

- Needed for about the first 10 weeks until the placenta takes over - Job is to make progesterone - Sometimes, it has to get removed due to an emergency (ex. ovarian torsion) - In this case, you can supplement with progesterone until the patient reaches 10 weeks

Components involved in the biophysical profile and what a score means.

- Nonstress test: reactive fetal heart rate monitoring - Amniotic fluid volume: single fluid pocket greater than or equal to 2 cm x 1 cm or amniotic fluid index >5 - Fetal movements: 3 or more general body movements - Fetal tone: 1 or more episodes of flexion/extension of fetal limbs/spine - Fetal breathing movements: 1 or more breathing episode for 30 or more seconds - Each gets 2 for normal - Score of 0-4/10 is placental dysfunction/insufficiency

What is a pubic symphysis diastasis?

- Normal diastasis (widening) of the pubic symphysis happens to facilitate vaginal delivery - However, after traumatic deliveries, patients can develop a symptomatic pubic symphysis diastasis - risk factors include fetal macrosomnia, forceps-assisted vaginal delivery and multiparity - Typically present with suprapubic pain that radiates to the back, hips and thighs or legs and is exacerbated by walking, weight-bearing, or position changes - Point tenderness to palpation over the pubic symphysis and sometimes have a waddling gait - Usually just supportive care - most recover within the first 4 weeks

What screenings are offered in each trimester for normal and high risk patients?

- Normal patients: 1st trimester - nuchal translucency, serum hCG, PAPP-A; 2nd trimester - quad screen - HIgh risk: can offer cell-free maternal DNA testing in first trimester

How much folid acid/day is recommended for low vs high risk patients during pregnancy?

- Normal: 0.4 mg/day - High risk (ex. previous neural tube defect): 4 mg/day

A baby is in a transverse lie prior to 37 weeks GA. What do you do?

- Nothing - Most babies will spontaneously convert to longitudinal lie and cephlic presentation by term (37 weeks)

3 complications of oligohydramnios? 4 complications of polyhydramnios?

- Oligo: meconium aspiration, preterm delivery, umbilical cord compression - Poly: fetal malposition, umbilical cord prolapse, preterm labor, preterm premature rupture of membranes

What obstetric complication is seen with indomethacin use?

- Oligohydramnios - Decreases prostaglandin production, leads to fetal vasoconstriction - This decreases renal perfusion and leads to oligohydramnios

What is the McRoberts maneuver?

- One of the first steps to try to fix shoulder dystocia during delivery - Flex mom's hips against the abdomen - You can also try to apply suprapubic pressure

What is the only indication for HRT in women with menopause?

- Only indicated to treat vasomotor symptoms in women <60 who have undergone menopause within the past 10 years

Increased AFP levels?

- Open neural tube defects - Abdominal wall defects

Intrauterine fetal demise with growth restriction, multiple limb fractures and a hypoplastic thoracic cavity?

- Osteogenesis imperfecta

Production of what is stimulated by suckling?

- Oxytocin - milk release - Prolactin is milk production

Fiery red mottled area on the vulva with whitish hyperkeratotic area. What is the diagnosis?

- Paget's disease of teh vulva

Criteria for cervical insufficiency?

- Painless cervical dilation in the current pregnancy (examination based) OR - A second-trimester cervical length of less than or equal to 2.5 cm plus a prior preterm delivery OR - 2 or more consecutive painless second-trimester losses - These patients get prophylactic cerclage

What is pseudothrombocytopenia?

- Patient will have mild thrombocytopenia found incidentally with no associated symptoms (ex. bruising, mucocutaneous bleeding), no family history of bleeding, and no abnormal physical exam findings - Blood smear shows large clumps of platelets - Usually a laboratory error

What anti-depressant should be avoided in pregnancy?

- Paxil

Patient with an IUD. Loses her period completely. All of a sudden, starts having spotting again and pelvic pain. 3 sexual partners in the last year. What is the most likely cause?

- Pelvic inflammatory disease

Two most common causes of postpartum urinary retention?

- Perineal trauma from a prolonged second stage of labor and/or perineal laceration that results in a pudendal nerve injury - Reduced sensory and motor sacral spinal cord impulses from epidural anesthesia which cause reduce detrusor tone, resulting in bladder atony

What is mammary Paget disease? What do a lot of patients with Paget disease have?

- Persistent, eczematous and/or ulcerating rash localized to the nipple and then spreads to the areola - Approximately 85% of these people have an underlying breast cancer, adenocarcinoma is the most common

What is the presentation of a Candida infection of the nipples?

- Pink and shiny with peeling at the periphery

First step in protracted labor?

- Place an intrauterine pressure catheter - If the pressure is sufficient, then you would try pitocin

How do you confirm acute hemolytic transfusion reaction?

- Positive direct Coombs test

You place an intrauterine pressure catheter and a lot of blood comes out of the vagina. What do you do next?

- Possibility of uterine rupture or placental abruption - Need to withdraw the IUPC, monitor the fetus, and then if reassuring, can try placing again

What complication can maternal indomethacin cause?

- Premature constriction/closure of the ductus arteriosus, especially if used after 32 weeks B

How to treat recurrent cystitis linked to intercourse?

- Prescribe post-coital antibiotics

What pregnancy risks are associated with ulcerative colitis?

- Preterm delivery and small for gestational age

What are some complications of PPROM?

- Preterm labor, intraamniotic infection, placental abruption, umbilical cord prolapse

What is the biggest risk factor for ectopic pregnancy?

- Previous ectopic pregnancy

Risk factors for placenta previa?

- Prior cesarean delivery - Prior placenta previa - Multiple gestations - Advanced maternal age

How to treat endometrial hyperplasia?

- Progestin therapy if patient desires future fertility

What is the management of ovarian torsion?

- Prompt laparoscopy

What is a rare and life-threatening pulmonary complication of severe preeclampsia?

- Pulmonary edema

What thyroid treatment is contraindicated in pregnancy?

- Radioactive iodine

What is ovarian hyperstimulation syndrome?

- Rare complication of ovarian induction for infertility - Ovulation agents stimulate artificial maturation of multiple ovarian follicles in these patients (bilateral, enlarge, cystic ovaries with multiple follicles is what you would see) - Also causes over-expression of VEGF causing increased vascular permeability and capillary leakage - this causes massive extravascular fluid shifts and leakage into the peritoneal cavity leading to ascites and abdominal distention

Malodorous, tan-brown discharge from the vagina?

- Rectovaginal fistula

Definition of recurrent pregnancy loss and what to do if it caused by an asymptomatic fibroid?

- Recurrent pregnancy loss - 3 or more consecutive losses - Hysteroscopic myomectomy - restores normal uterine anatomy therby reducing the risk of future pregnancy loss

Typical presentation of endometrial polyps?

- Regular monthly menses and additional intermenstrual bleeding - Not a lot of pain as with fibroids or endometriosis or adenomyosis

What is a common risk factor for hypermagnesemia in pregnant patients?

- Renal insufficiency

In women with Mullerian agenesis, what other organ system should be evaluated?

- Renal system with a renal ultrasound - These patients often have concurrent renal abnormalities that you need to check for

How do you manage a patient who has still not delivered after 40 weeks?

- Routine fetal monitoring with nonstress test and amniotic fluid volume - Signs of uteroplacental insufficiency: late decelerations on a non-stress test or single deepest amniotic fluid pocket less than <2 cm deep - If either of these, immediately deliver - If not, keep monitoring and they can stay in until 42 weeks

What is a rare side effect of oxytocin and what can it cause?

- Severe hyponatremia - Can cause a seizure

Describe the appearance/feel and location of a Bartholin duct cyst?

- Soft, mobile, nontender cystic mass palpated behind the posterior labium majus

What are signs that a baby is getting sufficient milk? (4)

- Sounds of swalloing - Weight gain - Three to 4 stools in 24 hours - Six wet diapers in 24 hours

A woman is taking a GnRh agonist to shrink a fibroid, and she discontinues the medication suddenly because she doesn't like the side effects. What will happen with the fibroid?

- Start growing again at teh same rate as before

How should a lupus flare be treated during pregnancy?

- Steroids

Hypertension increases the risk of what in pregnancy?

- Superimposed Preeclampsia, abruptio placentae, fetal growth restriction, preterm labor, stillbirth

Definition of fetal tachycardia?

- Sustained fetal heart rate >160/min

Compare symmetric vs asymmetric growth restriction: definition, onset, cause, clinical features

- Symmetric: estimated fetal weight <10th percentile for GA, onset in 1st trimester, caused by chromosomal abnormalities or congenital infection, global growth lag - Asymmetric: same definition but onset in 2nd/3rd trimester, caused by placental insufficiency (hypertension, pregestational diabetes), head-sparing growth lag (head is bigger than body)

What causes HELLP syndrome?

- Systemic inflammation and platelet consumption

Infection of an urethral diverticulum is what?

- Tender anterior vaginal wall mass with an associated expressed purulent or bloody urethral discharge - Causes incontinence because the abnormal outpouching can collect and store urine which results in postvoid dribbling

What is the mechanism that causes hypotension in a patient who receives an epidural?

- The anesthesia blocks the sympathetic nerves - This results in vasodilation (venous pooling), decreased venous return to the right side of the heart, and decreased cardiac output

What is the cause of infertility in many couples (up to 25% of cases) and how do you evaluate it?

- The male factor - Semen analysis

Is the presence of genital warts a risk factor for cervical cancer?

- The warts themselves will not become malignant but the presence of them indicates a person who is at a higher risk overall because they are already infected with some strain of HPV

What is the correct order of these: menarche, thelarche, growth spurt, adrenarche

- Thelarche (breast budding) - Adrenarche (hair grwowth) - Growth spurt - Menarche

What type of cysts can hydatidiform moles cause, what do they look like on imaging, and how does it cause them?

- They can cause bilateral, theca lutein cysts - Bilateral, multilocular, ovarian cysts - Caused by ovarian hyperstimulation from markedly elevated b-HCG levels

Why can uterine leiomyomas cause a breech presentation?

- They can distort the uterine cavity and limit fetal mobility

Treatment of lichen sclerosus?

- Topical corticosteroids

28 year old female, G1P0, 16 weeks gestation to establish care. History of cold knife conization 2 years ago for HSIL. Best way to evaluate her risk for preterm labor?

- Transvaginal ultrasound - Biggest risk factor for preterm labor is preterm labor in a prior pregnancy - Other risk factors include multiple gestations and a history of cervical surgery - removal of part of the cervix by the cold knife can cause cervical scarring/stenosis and cervical incompetence - Transvaginal ultrasound can assess cervical length - short cervical length is a strong predictor of preterm labor

Thick-walled multiloculated mass filled with debris obliterating the adnexa?

- Tubo-ovarian abscess

What size babies associated with type 1 diabetes vs. gestational diabetes?

- Type 1: usually SGA babies - Gestational: usually LGA babies

What is the best method for estimating fetal weight?

- Ultrasound

What is the most common cause of an elevated AFP level?

- Under-estimation of gestational age - Once that is ruled out, it is an abdominal wall defect

What incontinence can menopause cause?

- Urgency incontinence

Leiomyoma uteri is the same thing as?

- Uterine fibroids

Mobile, globular mass with several protuberances located below the umbilicus?

- Uterine fibroids - Protuberances aka irregular uterus

Typical presentation of placental abruption?

- Variable amount of vaginal bleeding - Abdominal and/or back pain - Fetal heart rate abnormalities - Remember, hypertension is the most common risk factor!!

How to distinguish vasa previa from placenta previa?

- Vasa previa: minimal, painless bleeding; leads to fetal demise within minutes so might say they can't detect fetal heart tones - Placenta previa: heavy, painless bleeding, mom might come in in shock if she's lost enough blood

When can you deliver vaginally vs not in a patient with HIV?

- Viral load < 1000 - ok to deliver vaginally - More than 1000 - should do cesarean delivery

If a patient comes in with symptoms of incontinence but the symptoms seem mixed between multiple types, what is the next best step in management?

- Voiding diary - In order to determine the main type and treat properly

Patient with previous lichen sclerosus puts them at increased risk for what?

- Vulvar squamous cell cancer

What is physiologic leukorrhea?

- White, odorless, cervical discharge composed of cervical mucus, normal vaginal flora, and vaginal squamous epithelium

Can breast engorgement cause fever?

- Yes, doesn't necessarily mean an infection

The presence of endometrial cells in postmenopausal females means what?

- You should do an endometrial biopsy

What is septic pelvic thrombophlebitis?

- complications associated either with pelvic surgery or the postpartum period - Thrombosis of the deep pelvic or ovarian veins that become infected - Persistent postpartum fever unresponsive to broad-spectrum antibiotics and a negative infectious evaluation - it is a diagnosis of exclusion

Management of acute hemolytic transfusion reaction?

- fIrst step: stop transfusion - Then aggressively hydrate with normal saline

diffuse rash in pregnancy with on prenatal care, rash involves the palms and soles?

- secondary syphillis

Explain the clinical presentation and ultrasound findings of the following: - Mittelschmerz - Ectopic pregnancy - Ovarian torsion - Ruptured ovarian cyst - Pelvic inflammatory disease

-Mittelschmerz: recurrent mild and unilateral mid-cycle pain prior to ovulation; pain lasts hours to days; ultrasound is not indicated - Ectopic pregnancy: amenorrhea, abdominal and pelvic pain and vaginal bleeding; positive beta-hcg; no intruterine pregnancy on ultrasound - Ovarian torsion: sudden-onset, severe, unilateral lower abdominal pain, nausea and vomiting; unilateral, tender adnexal mass on examination; enlarged ovary on ultrasound with decreased or absent blood flow - Ruptured ovarian cyst: sudden-onset, severe, unilateral abdominal pain immediately following strenous or sexual activity; pelvic free fluid on ultrasound - Pelvic inflammatory disease: fever, chills, vaginal discharge, lower abdominal pain and cervical motion tenderness; may or may not have tuboovarian abscess on ultrasound

What labs should be performed at each of these visits: 1) Initial prenatal visit 2) 24-28 weeks 3) 35-37 weeks

1) Initial prenatal visit: Rh type/antibody screen, hemoglobin/hematocrit/MCV, HIV, VDRL/RPR, HBsAg, Rubella and Varicella immunity, Pap test, Chlamydia PCR, urine culture, urine protein 2) 24-28 weeks: hemoglobin/hematocrit, antibody screen if Rh(D) negative, 1 hour glucose tolerance test 3) 35-37 weeks: Group B strep culture

Explain the difference between the 5 abortion types: 1) Missed 2) Threatened 3) Inevitable 4) Incomplete 5) Complete

1) Missed: No vaginal bleeding, closed cervical os, no fetal cardiac activity or empty sac 2) Threatened: Vaginal bleeding, closed cervical os, fetal cardiac activity 3) Inevitable: Vaginal bleeding, dilated cervical os, products of conception may be seen or felt at or above cervical os 4) Incomplete: Vaginal bleeding, dilated cervical os, some products of conception expelled and some remain 5) Complete: Vaginal bleeding, closed cervical os, products of conception completely expelled

A 49 year old woman, G5P5, comes to the office due to urine leakage. Over the last 2 months, the patient has had constant urinary leaking, requiring her to wear a pad day and night. She has no dysuria, urgency or vulvar pruritis. The patient has type 2 DM that is well controlled with oral medication. Two years ago, she received brachytherpay and external-beam pelvic radiation for cervical cancer. She had smoked a pack of cigarettes daily for 25 years but quit 6 years ago. BMI is 43. Pevlic examination shows no urethral leakage with Valsalva. There are postradiation changes and a pool of clear fluid in the vagina. Postvoid residual volume is 20 mL. What is the most likely cause of this? A. Aberrant connection between the bladder and the vagina B. Decreased urethral sphincter muscle tone C. Diminished contractility of the bladder detrusor D. Excessive involuntary detrusor muscle spasms E. External compression of the urethral outlet F. Urethral hypermobility from weakened pelvic floor muscles

A. Aberrant connection between the bladder and vagina - Remember, constant watery urinary leakage = vesicovaginal fistula

A 37 year old woman comes to the office for evaluation of abnormal vaginal discharge. She noticed increased clear, watery vaginal discharge 4 months ago and now has intermenstrual bleeding. She reports no pruritus or dysuria. The patient is sexually active with a male partner and uses condoms for contraception. She has had 5 lifetime partners. She has no medical problems or previous surgeries. The patient has a 24-pack year smoking history but does not use alcohol or illicit drugs. Blood pressure is 120/70, and pulse is 88. On pelvic examination, a raised, ulcerative lesion is noted on the cervix and clear discharge is present. The vaginal mucosa is not erythematous and has no lesions. The uterus is small, mobile, and anteverted, with no adnexal masses or cervical motion tenderness. No inguinal lymphdenopathy is present. Which of the following is the next best step in the diagnosis of this patient's condition? A. Cervical biopsy B. Herpes simplex virus C. Nucleic acid amplification testing for G and C D. Pelvic Ultrasound E. Wet mount of cervical mucus

A. Cervical biopsy - Cervical lesion, vaginal discharge, intermenstrual bleeding - concern for cervical cancer

A 34 year old woman comes to the office for evaluation of vulvar lesions that have worsened over the past 3 months. She has had 2 sexual partners in the last year. Medical history includes genital infection with herpes simplex virus when she was 23; when she was 25, her sexual partner was diagnosed with syphilis. Cervical cancer screening last year revealed atypical squamous cells of undetermined significance, with negative testing for high-risk HPV. The patient smokes cigarettes but does not use alcohol or illicit drugs. Examination reveals multiple nontender, fleshy, verrucous growths, clustered at the vestibule of the vulva and over the labia majora. A few lesions are friable and bleed with manipulation. The remainder of the examination is normal. Which of the following is the most likely diagnosis in this patient? A. Condylomata acuminata B. Condylomata lata C. Genital herpes D. Lichen planus E. Lichen sclerosus F. Molluscum contagiosum G. Vulvar cancer

A. Condylomata acuminata - Patients with chronic tobacco use or immunosuppression are at a higher risk for low-risk HPV strains - Genital warts are typically asymptomatic and nontender, although pruritis friable lesions may occur - Condylomata lata - caused by secondary syphilis - gray-white lesions that develop on mucosal surfaces - Herpes simplex - tender ulcerative blisters or pustules - Lichen sclerosus - pruritic white lesions that are thin and wrinkled - Molluscum - pearly lesions with central dimpling - Vulvar cancer - smokers are at increased risk; single, friable, fleshy vulvar lesion; however, associated with high risk HPV strains and this person has a recent negative HPV screen

A 38 year old woman, G1P0, at 38 weeks gestation, is brought to the ED with sudden vaginal bleeding and severe lower abdominal pain. The patient had a prenatal course notable for diet-controlled gestational diabetes. An ultrasound at 20 weeks gestation showed normal fetal anatomy and a fundal placenta. The patient has a 5 pack year smoking history, and has been trying to quit. Her temperature is 98.7, blood pressure is 158/96, and pulse is 112. Physical examination shows uterine tenderness and moderate vaginal bleeding. Digital cervical examination shows a 3-cm dilated cervix with the fetus in vertex presentation at 0 station. Fetal heart tracing shows 140/min with accelerations and moderate variability. Contractions occur every 2 minutes and last for 20 seconds. Urinalysis shows 3+ protein. This patient is at greatest risk for developing which of the following complications? A. DIC B. Intra-abdominal hemorrhage C. Retained placenta D. Septic shock E. Umbilical cord prolapse

A. DIC - This is placental abruption - Complications include hypovolemic shock and DIC

A 29 year old female comes to the ED due to fever, chills and lower abdominal pain. Two days ago, the patient underwent dilation and curettage for a 9 week missed abortion. After the procedure, she initially had light spotting, but the bleeding has become increasingly heavy and malodorous within the last few hours. She has also developed increasing abdominal pain and a fever unrelieved by acetaminophen. The patient has no chronic medical conditions and has had no other surgeries. Temperature is 103 F blood pressure is 88/50 and pulse is 118. On speculum examination, the cervix is visibly 1 cm dilated and has purulent discharge at the os. The uterus is enlarged and has cervical motion tenderness. Transvaginal ultrasound shows a thickened endometrial stripe. Urine pregnancy test is positive. The patient is started on broad-spectrum antibiotics and undergoes a suction dilation and sharp curettage. This patient is at an increased risk for which of the following? A. Development of intrauterine synechiae B. Dysplastic changes to the cervical epithelium C. Implantation of ectopic endometrial tissue D. Infarction of the pituitary gland E. Malignant transformation of trophoblastic tissue

A. Development of intrauterine synechiae - Septic abortion - During a suction dilation with sharp curettage, the endometrium can be moved along with the conception material - This denudes the endometrial basalis layer and causes an inflamed, oblitearated uterine cavity prone to intrauterine synechiae development

A fetal heart traing has minimal variability and no accelerations. Which one of these should you do next? A. Digital fetal scalp stimulation B. Fetal scalp pH C. Amnioinfusion D. Allis clamp pinching of the fetal scalp E. Place mother in hands and knee position

A. Digital fetal scalp stimulation - You're trying to stimulate baby to get the tracing better

31 year old female follow up abnormal Pap test. two weeks ago Pap testing revealed a HSIL. Colposcopy reveals a nulliparous cervix with no raised or ulcerated lesions. The entire squamoudcolumnar junction cannot be visualized. What is teh next best step? A. Endocervical curettage B. Endometrial biopsy C. HPV testing in 5 years D. Repeat pap testing in 1 year E. Transvaginal pelvic ultrasound

A. Endocervical curettage - HSIL are very high risk - Colposcopy didn't show much, but it wasn't sufficient because you couldn't see the whole junction - If this is the case, you have to do endocervical sampling

A 60 year old woman, G3P3, comes to the office due to shortness of breath. Over the past 6 months, the patient has been finding it progressively more difficult to take deep breaths. She has also noticed that she cannot fit into any of her pants lately despite a decreased appetite and nausea. The patient has no history of type 2 diabetes and has never had any surgeries. All her children were born vaginally. Routine mammography 4 years ago was normal. The patient has a sister with breast cancer, BRCA positive. Physical examination shows an ill-appearing woman with a distended abdomen and decreased bowel sounds. The lungs are clear on auscultation. Pelvic examination shows a firm, nodular, non-mobile mass in the left adnexa. A pelvic examination is performed and confirms the physical examination findings. Which of the following is the most appropriate next step in management of this finding? A. Exploratory lapraotomy B. Hysteroscopy C. Image-guided biopsy of pelvic mass D. Loope electrosurgical excision procedure E. Myomectomy

A. Exploratory laparotomy - Epithelial ovarian cancer - Exploratory laparotomy is required for surgical staging

A 40 year old woman, G2P1, comes to the physician for her first prenatal visit. She is at 10 weeks gestation based on her last menstrual period. The patient has no medical problems and takes no medications. Her husband and 3 year old son are healthy but she has a cousin with Down Syndrome. Vital signs are normal. Urine b-Hcg is positive and fetal heart tones are present. Which of the following is the most appropriate next step in management of this patient? A. Order plasma cell free DNA testing B. Order serum alpha-fetoprotein, estriol, b-hcg, and inhibin A levels C. Order serum pregnancy-associated plasma protein A level D. Perform amniocentesis E. Perform chorionic villus sampling

A. Order plasma cell free fetal DNA testing - This woman's age makes her at an increased risk for aneuploidy - Cell-free fetal DNA testing can be performed from 10 weeks on and is less invasive - If she didn't meet criteria for this test, then you would do option B

32 year old at 21 weeks comes in with increasing vaginal discharge. Started a week ago, initially clear but now bloody. No abdominal pain or heavy bleeding. No medical history of surgeries. Vitals signs relatively normal. The uterus is nontender, fundal height 19 cm and fetal heart tones 155. Speculum exam shows scnat blood and discharge; a bulging bag with fetal parts is protruding through the cervix, whcih is dilated 4 cm. Microscopy of teh vaginal discharge shows sqaumous epithelial cells and few leukocytes. Nitrazine testing negative. What is this? A. Abruptio placentae B. Cervical insufficiency C. Incomplete abortion D. Preterm labor E. PPROM

B. Cervical insufficiency - Don't confuse this with incomplete abortion, which is defined as loss at less than 20 weeks - this patient is at 21 weeks

A 34 year old woman, G3P2, at 33 weeks gestation, comes to the ED due to continued leakage of fluid. The patient reports intermittent vaginal spotting, but has had no contractions. Fetal movement is normal. Her prenatal course has been complicated by group B Streptococcus bacteruria treated in the first trimester. The patient has no other chronic medical conditions or previous surgeries. Temperature is 102.5, blood pressure is 90/56, and pulse is 109. Fundal height measures 30 cm. Speculum examination shows pooled fluid in the posterior fornix that turns nitrazine paper blue; the cervix appears visibly closed. A ferning pattern is visualized on microscopy. Fetal heart monitoring shows a rate of 170 with moderate variability. Tocometry shows no contractions. A transabdominal ultrasound reveals a fetus in transverse lie, the single deepest pocket of amniotic fluid is 1 cm. Which of the following is an indication for delivery in this patient? A. Fetal malpresentation B. Fetal tachycardia C. Gestational age D. Group B strep colonization E. Uterine size-date discrepancies

B. Fetal tachycardia - This patient has PPROM - Complication is chorioamnionitis b/c she has been exposed - Fever, sustained fetal tachycardia, maternal leukocytosis and/or purulent amniotic fluid - When patients present with overt sings of infection, it doesn't matter the gestational age, you deliver the baby

A 27 year old female at 40 weeks gestation has a forceps-assisted vaginal delivery after pushing for 2 hours. She was diagnosed with preeclampsia with severe features on admission and is receiving a magensium sulfate infusion. Her first pregnancy ended with a C delivery at 39 weeks gestation for breech presentation. Temperature is 99 F, blood pressure is 150/100, and pulse if 112. Ten minutes after delivery the placenta delivers with gentle traction and the patient develops profuse vaginal bleeding. Bimanual massage reveals a firm, nontender uterus with the fundus at the level of the umbilicus. Pelvic examination shows a right vaginal sidewall defect. There is minimal bleeding from the cervical os, and the perineum is intact. Which of the following is the most likely cause of his patient's bleeding? A. Endometritis B. Genital tract trauma C. Placenta accreta D. Uterine atony E. Uterine rupture

B. Genital tract trauma - Vaginal sidewall defect + Minimal bleeding from the cervical os - most likely vaginal laceration

A 49 year old woman comes to the ED for evaluation of back pain. The patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy for ovarian cancer 1 week ago. She had an uncomplicated postoperative course, with her Foley catheter removed on postoperative day 2. She was discharged home on postoperative day 4. The patient noted some right-sided back pain after surgery that improved with pain medications. However, the pain has become more severe and is no longer responding to pain medications. The pain dow not radiate, and now she has associated nausea and vomiting. Temperature is 99, blood pressure is 128/72, and pulse is 92. BMI is 38. The abdominal incision is closed and has no erythema, drainage or fluctuance. There is mild right constovertebral angle tenderness; the left side is nontender. Serum creatinine is 0.8. Catherterized urinalysis is normal. Which of the following is the most likely cause of this patient's pain? A. Acute pyelonephritis B. Hydronephrosis C. Nephrolithiasis D. renal infarction E. Renal vein thrombosis

B. Hydronephrosis - Remember, risk for ureteral injury with any gynecologic surgery, but particularly hysterectomies

A 25 year old woman at 24 weeks gestation comes to the office in mid-November for a routine prenatal visit. She has felt normal fetal movement and no abdominal pain, vaginal bleeding, or leakage of fluid. Three days ago, the patient's 5 year old son was diangosed with varicella, however, she has not had fever, malaise or a rash. The patient has no chronic medical conditions or previous surgeries. She takes a prenatal vitamin and iron supplement. Blood pressure is 110/60 and pulse is 64. BMI is 27. Physical exam shows no rash or lymphadenopathy. Fundal height is appropriate for gestational age. The fetal heart rate by bedside Doppler is 145. The patient's prenatal lab results show: Rubella IgG - negative Rubella IgM - negative Varicella-zoster IgG - positive Varicella-zoster IgM - negative Which of the following is the next best step? A. H. influenzae type b conjugate vaccine B. Influenza virus vaccination C. Measles-mumps-rubella vaccination D. Varicella vaccination E. Varicella-zoster immunoglobulin

B. Influenza virus vaccination - She doesn't need the Hib (not high risk) - Not immune to rubella based on labs, but she can't get that vaccine during pregnancy - She has positive IgG varicella antibodies so she is immune

A 36 year old nulligravida comes to the office for an infertility evaluation. Eight months ago, she was found to have a submucosal fibroid and underwent an uncomplicated hysteroscopic resection. The patient had light spotting for several days after surgery but not fever or abnormal vaginal discharge. Her last menstrual period was immediately prior to the procedure, but now she has monthly pelvic pain and no bleeding. The patient has had regular, unprotected intercourse for the last 6 months without conception. She has no medical problems and has had no other surgeries. Vital signs normal. Uterus is small, mobile and nontender. Pregnancy test is negative. FSH, TSH and prolactin levels are normal. STI screen is negative. A progesterone withdrawal test does not induce vaginal bleeding. Which of the following is the most likely cause of this patient's infertility? A. Endometriosis B. Intrauterine synechiae C. Recurrent fibroid D. Tubal occlusion E. Uterine septum

B. Intrauterine synechiae - In women older than 35, infertility is inability after 6 months - Infertility and secondary amenorrhea after a procedure like hers - think asherman syndrome - development of symptomatic intrauterine synechiae

A 44 year old woman comes to the office due to night sweats and insomnia. For the past month, she has awakened completely soaked with perspiration almost every night. She has also had difficulty concentrating at work. The patient has had irregular menstrual periods for the past 5 months. She has a history of hypertension controlled with medication. The patient quit smoking 5 years ago and does not use illicit drugs. She typically has an alcoholic drink before bed. Temp is 98, blood pressure 140/90, pulse 80, resp 14. Skin is normal and there is no periorbital edema. The thyroid is non enlarged and nontender, and there are no masses. Abdominal examination is normal. The uterus is small and anteverted and the vagina has minimal rugation. There are no palpable adnexal masses. urine pregnancy test is negative. Which of the following is the next best step in management of this patient? A. Measure 24-hour urinary catecholamines B. Measure serum TSH and FSH C. Order urine tox screen D. Prescribe oral hormone replacement E. Provide reassurance and education about menopause

B. Measure serum TSH and FSH - In this age group, these symptoms could also be caused by a thyroid problem so you need to confirm menopause with this testing

What is the strength of using a fetal fibronectin test in patients with preterm contractions? A. Positive predictive value B. Negative predictive value C. High sensitivity D. Low false positive rate E. High false positive rate

B. Negative predictive value - About 99% in patients

A 31 year old G1P0010 woman presents for preconception couseling. She has a history of a 19 week loss thought to be due to cervical insufficiency. At the time, she presented with painless cervical dilation, and proceeded to deliver a non-viable fetus who expired. She wants to know how this pregnancy should be managed. Which of the following interventions is most effective for managing her cervical insufficiency? A. Prophylactice transabdominal cerclage B. Prophylactic transvaginal cerclage C. Check her cervix often, and if preterm dilation occurs, perform rescue cerclage D. Restrict activity and maintain bed rest E. Maintain pelvic rest during pregnancy (avoid intercourse

B. Prophylactic transvaginal cerclage - A patient with a history of cervical insufficiency is a candidate for this

A 27 year old G1 woman at 36 weeks gestation is undergoing induction of labor for preeclampsia with severe features. She complains of a headache, right upper quadrant pain and seeing spots. Admission vital signs are 180/120, resp 20, pulse 92. Fetal heart rate is 144 bpm. In addition to 10 hours of oxytocin, she is receiving intravenous mag sulfate 2 g/hour. During the past 2 hours, her urine output has decreased to 20 mL/hr (down from 40) and her respiratory rate is now 10/min. Pulse oximetry is 88%. The fetal heart rate tracing is category 1. What is the next best step in management? A. Continue mag sulfate B. Decrease mag sulfate to 1 g/hour C. Administer calcium gluconate D. Increase oxytocin drip E. Cesarean delivery now

C. Administer calcium gluconate - She has respiratory depression which is a sign of mag sulfate toxicity

Lady comes in a 28 weeks GA. ROM has happened. Baby has anencephaly. What do you do? A. Administer corticosteroids B. Administer magnesium sulfate C. Allow spontaneous vaginal delivery D. Amnioinufusion and tocolysis E. Perform Cesarean delivery

C. Allow spontaneous vaginal delivery - Principle behind labor management of patients with lethal fetal anomalies is to minimize maternal mortality and morbidity - Vaginal delivery has a lower risk of complications

A 41 year old woman, G1P1, comes to the office to discuss possible contraceptive options. She was recently diagnosed with hypertension and started on an ACE inhibitor. While discussing the medication, the patient was counseled on the risk of ACE inhibitors in pregnancy and the need to reliable contraception. She has not been on contraception for the past year because she was breastfeeding up until a month ago. Her husband does not want any more children, but the patient is unsure about future pregnancy. She has no other chronic medical conditions and takes no other medications. Her menses are monthly with 4 days of light bleeding and mild cramping on the first day. She does not use tobacco, alcohol or illicit drugs. Blood pressure is 122/78, and pulse is 70. BMI is 19. On pelvic examination, the cervix is multiparous and has no visible lesions. The uterus is mobile and nontender. Which of the following is the most appropriate contraceptive option for this patient? A. Bilateral tubal ligation B. Combined oral contraceptive pills C. Copper-containing IUD D. Estrogen progestin vaginal ring E. Vasectomy in husband

C. Copper IUD - Don't want hormones because of her hypertension - Don't want non-reversible options

A 34 year old woman, G2P2 is evaluated on the postpartum floor for nausea and lightheadedness. The patient developed these symptoms when she tried to ambulate to the bathroom, forcing her to immediately lie down. Earlier today, she underwent a repeat C delivery at 39 weeks gestation; she is taking scheduled NSAIDS for incisional pain. The patient is fatigued and feels like she can barely keeps her eyes open. She has no chronic medical problems and takes no daily medications. Blood pressure is 80/50, pulse is 124, and respiration are 18. The patient appears pale and has cold skin. The uterine fundus is firm at the umbilicus and the abdomen is tender but has no increased bleeding from the incision site. On pelvic examination there is minimal lochia and no clots. Which of the following is the next best step in management? A. Antiemetics and serial examinations B. CT scan of the abdomen and pelvis C. Emergency laparotomy D. Oxytocin infusion and fundal massage E. Transvaginal ultrasound

C. Emergency laparotomy - She is showing signs of postpartum hemorrhage and since she has no obvious external source, she has to be bleeding from inside

A 39 year old woman, G4P0, at 35 weeks gestation comes to the hospital due to intense, constant lower abdominal pain. The patient conceived via in virto fertilization, her prenatal course has been uncomplicated. Over the past 10 years, the patient has had 3 spontaneous abortions, all attributed to uterine leiomyoma. Two years ago, she had an abdominal myomectomy during which the uterine cavity was entered. Temperature is 98, blood pressure is 130/80, pulse is 100. The fetal heart tracing shows a baseline rate in the 140s with moderate variability and persistent variable decelerations to the 90s. Contractions occur every 2-3 minutes and last for 45 seconds. The cervix is 4 cm dilated and 100% effaced. Which of the following is the best next step in management of this patient? A. Expectant management and spontaneous vaginal delivery B. Intrauterine pressure catheter and amnioinfusion C. Laparotomy and cesarean delivery D. Operative vaginal delivery E. Subcutaneous administration of terbutaline

C. Laparotomy and cesarean delivery - The risk of uterine rupture is increased in this patient because of the prior uterine surgery - She is likely experiencing uterine rupture and so you must delivery with a C delivery

38 year old woman at postoperative visit due to incisional pain after abdominal hysterectomy. 500 ml blood loss during surgery. After surgery, heparin was administered for venous thromb prophylaxis and discontinued when she started ambulating. Since leaving the hospital, the patient has had incisional pain and light bleeding. In addition, she feels a pulling sensation tot he left of her incision that worsens when she bends over and when she strains to have a bowel movement. Vital signs normal. BMI 34. The abdomen is soft and has normal bowel sounds. The low horizonal abdomianl incision is closed with staples, and the skin edges are intact. There is mild incisional induration but no erythema, drainage or fluctuance. The incision is diffusely tender to deep palpation and no palpable masses or defects are preesent. Hemoglboin is 9 and leukocytes are 10,000. What is the next best step? A. CT scan of abdomen and pelvis B. Incisional exploration and packing C. Observation and reassurance D. Oral antibiotic therapy E. Pelvic ultrasound

C. Observation and reassurance - Post-operative inicisonal pain after abdominal surgery is completely normal - No signs of infection, fluid collection or wound dehiscense

A 29 year old woman at 25 weeks gestation comes to the clinic for routine prenatal care. She has a history of chronic hepatitis C infection acquired approximately 10 years ago. Her pregnancy has been otherwise uncomplicated to date. She is married and is monogamous with her husband who is aware of her hepatitis infection. Her past medical history is significant only for an appendectomy at age 12. She has not been immunized against hepatitis A or B. She takes no medications, aside from a daily prenatal vitamin. Which of the following recommendations should be given to this patient? A. Avoid breastfeeding the baby B. Begin treatment with inteferon and ribavirin C. Obtain hepatitis A and B vaccinations now D. Schedule an elective cesarean delivery E. Use barrier protection for all sexual intercourse

C. Obtain hepatitis A and B vaccinations now - Breastfeeding is fine unless the nipple is bleeding - The medications for hepatitis C are not safe during pregnancy - C delivery doesn't decrease the risk of vertical transmission

Which of the following interventions could reduce the risk of PPROM? A. Bedrest B. Placement of a cerclage C. Placement of a terbutaline pump D. 17-alpha hydroxyprogesterone E. Nifedipine

D. 17-alpha hydroxyprogesterone

24 year old at 10 weeks gestation develops severe vomiting. Breath sounds are equal but a retrosternal crunching sound is heard with each heartbeat. What is the most likely cause? A. Acute pancreatitis B. Aspiration pneumonitis C. biliary colic D. Esophageal perforation E. Mallory-weiss syndrome F. Reflux esophagitis

D. Esophageal perforation - Mallory-Weiss isn't severe enough to cause the damage making the crunching sound - This indicates a full-thickness tear

A 35 year old woman, G4P1A2, comes to the office for her first prenatal visit. Her last menstrual period was 7 weeks ago, and she is concerned about some vaginal bleeding and cramping. A home pregnancy test was positive just after the patient's missed period; around that time, she experienced nausea that has since subsided. She has had 1 normal term delivery and 2 early first-trimester losses. Six months ago, she had an episode of sudden right arm weakness and slurred speech; which resolved spontaneously in approximately 2 hours. The patient takes prenatal vitamins and no other medications. BMI is 30. Blood pressure is 140/80. Pelvic examination shows a closed cervix, no vaginal bleeding and a slightly enlarged, irregularly shaped uterus. Ultrasound shows an empty uterus with one subserosal fibroid about 2 cm in diameter. b-hCG is 23. Which of the following maternal factors is the most likely cause of this patient's miscarriage? A. Balanced maternal translocation B. Demyelinating lesions C. Fibroid uterus D. Hypercoagulability E. Insulin resistance F. Subclinical uterine infection G. Thyroid disease

D. Hypercoagulability - This is anti-phospholipid syndrome

A 20 year old G2P1 woman at 28 weeks getation presents to labor and delivery with contractions every four minutes. On physical examination, her vital signs shows temp of 101, pulse 120, resp 18 and blood pressure 110/65. Her uterine fundus is tender and the rest of the physical exam is normal. Her cervix is dilated to 1 cm and is 50% effaced the fetus is in vertex presentation. Fetal heart tones are in the 150s with a category 1 tracing. Her white blood cell count is 18,000. What is the most appropriate next step in management of this patient? A. Observation B. Tocolysis C. Contraction stress test D. Labor induction E. Cesarean delivery

D. Labor induction - She has signs of an infection - you need to deliver - remember get AWAY from the infection by delivery

A 27 year old woman, G1P0, comes to the office for an initial prenatal visit. The patient is uncertain when her last menstrual period was, but she has had daily nausea and vomiting for the past 2 months. She has had no vaginal bleeding or pelvic pain. The patient has no chronic medical conditions, and has had no surgeries. She takes a daily prenatal vitamin. Vital signs are normal. Abdominal examination reveals a gravid uterus that is nontender, and the fundus is just below the umbilicus. Ultrasound shows 2 intrauterine fetal poles measuring 14 weeks gestation with heart rates of 150/min and 155/min. Cervical length is 4.5 cm. Which of the following is the next best step in management of this patient? A. Cerclage placement B. Indomethacin C. Intramuscular hydroxyprogesterone D. Low-dose aspirin E. Low-molecular weight heparin

D. Low dose aspirin - Multiple gestations put mom at risk for preeclampsia - This is the only proven strategy to reduce that risk

A 34 year old woman, G2P1, at 14 weeks gestation comes to the office for a routine prenatal visit. she is feeling well and has no concerns. The patient had daily nausea and vomiting for the first few weeks of pregnancy but symptoms resolved 2 weeks ago. She has had no pelvic pain or vaginal bleeding. The patient has not yet felt fetal movement. Her first pregnancy ended in a C delivery at 30 weeks gestation due to breech presentation and preeclampsia with severe features. The patient has no chronic medical conditions. Blood pressure is 124/74, BMI is 24. Fetal heart tones are 155/min. The uterus is gravid and nontender. The remainder of the examination is unremarkable. Which of the following is the best next step in management? A. Betamethasone B. High dose folic acid C. Intramuscular hydroxyprogesterone D. Low-dose aspirin E. Vaginal progesterone

D. Low-dose aspirin - Patient with predisposing factors to preeclampsia, such as chronic kidney disease, chronic hypertension and preeclampsia in a prior pregnancy are at high risk for developing preeclampsia - In high-risk patients, daily low-dose aspirin is the only therapy proven to decrease the risk of preeclampsia

Which of the following is the most important direct role of hCG in pregnancy? A. Inhibition of uterine contractions B. Induction of prolactin production by the pituitary C. Promotion and maintenance of implantation D. Maintenance of the corpus luteum E. Induction of early embryonic division and differentiation

D. Maintenance of the corpus luteum

A 37 year old, G2P1, at 8 weeks gestation comes to the office for a follow-up visit. Earlier in the pregnancy, the patient had nausea and breast tenderness that resolved several days ago. She has no other concerns. At her initial prenatal visit a week ago, ultrasound revealed an intrauterine gestational sac with a yolk sac but no fetal pole. B-hcg level at the time was 27,325. She is taking a prenatal vitamin and does not use tobacco, alcohol or illicit drugs. Current blood pressure is 140/80 and pulse is 68. BMI is 23. Pelvic examination reveals a closed cervix and no vaginal discharge or bleeding. Bimanual examination reveals a normal-sized, retroverted uterus with no cervical motion tenderness or adnexal tenderness. A transvaginal ultrasound i repeated and is unchanged from the prior visit. b-HCG level is now 25,659. Which of the following is the most likely diagnosis? A. Ectopic pregnancy B> Hydatidiform mole C. Incomplete abortion D. Missed abortion E. normal pregnancy F. Threatened abortion

D. Missed abortion - Ultrasound includes an embryo without cardiac activity an empty gestational sac with no fetal pole - Some early pregnancies can present with a fetal pole, like the first one did, but subsequent ultrasounds and b-hcg should show a fetal pole and increasing levels (not decreasing)

A 34 year old woman, G3P2, at 30 weeks gestation comes to the clinic for evaluation of an abdominal bulge. The patient first noticed this bulge 2 weeks ago when she was sitting up to get out of bed. She also sees the mass when she is straining to defecate or picking up her toddler. The patient has no nausea, vomiting, or abdominal pain, and her last bowel movement was 2 days ago. She has chronic constipation for which she takes a daily stool softener, and her prior surgeries include 2 cesarean deliveries. Temp is 99, blood pressure is 124/76, pulse is 92. Pre=pregnancy BMI is 19. When the patient sits up and performs the Valsava maneuver, a non-tender abdominal mass protrudes between the rectus abdominus muscles. When the patient is placed supine, no fascial defects are palpated. Bowel sounds are normoactive and there is no rebound or guarding. The uterus is non-tender and the fundal height is 30 cm. Which of the following is the best next step in management of this patient? A. Abdominal binder placement B. Immediate surgical repair of the defect C. MRI of the abdomen/pelvis D. Observation and reassurance E. Small bowel follow-through

D. Observation and reassurance - This is rectus abdominus diastasis - Unlike a hernia, there are no associated fascial defects with this

29 year old female comes in for evaluation of leakage of urine. For the past week, patient has had to urinate every hour and has had leakage of urine while trying to run to the bathroom. No hematuria, dysurai or flank pain. Has had 2 vaginal deliveries without complications. Vitals normal. On speculum exam, the bladder has nodescent but the patient leaks urine with Valsava maneuver. Urine dipstick is negative for protein, blood, glucose and ketones but positive for leukocyte esterase. Preganncy test negative. What is the next best step? A. Continence pessary placement B. Hemoglobin A1c C. Midurethral sling procedure D. Oral antibiotics E. Urodynamic testing

D. Oral antibiotics - This is just a UTI

24 year old woman, G1P0, 28 weeks gestation comes for routine visit. Has had no issues. No chronic medical conditions. At an initial visit in her first trimester, prentaal testing results were positive for Chlamydia., but negative for hepatitis B, HIV, and RPR. Her and her partner were treated with azithromycin, and had a negative test a month later. Blood pressure 118/74 and pusle 90. BMI 34. Urine dipstick testing reveals trace amounts of protein and glucose. A 1 hour glucose test, CBC, and C trachomatis test are ordered. What else is indicated today at this routine 28 week visit? A. 24 hour urine collection for protein B. Cervicovaginal fetal fibronectin C. Group B strep rectovaginal culture D. RPR assay E. ultrasound for cervical length

D. PRP assay - Patients who are at high risk for STDs like this patient who already had one require repeat testing in the 3rd trimester for all STIs

A 37 year old woman, G2P1, comes to the ED due to painful contractions and leakage of fluid. She has not received prenatal care during this pregnancy and is at 24 weeks GA by a sure, regular last menstrual period. The patient has no chronic medical conditions. She precipitously delivers a male fetus with no cardiac activity. Examination of the fetus shows edematous, peeling skin. The scalp is edematous, but the palate appears normal and there are no dysmorphic facial features. The fetal abdomen is tense and fluid-filled. The placenta appears thickened and edematous. Maternal labs show O, RH negative blood, negative indirect Coombs, negative HIV antibody. Which of the following is the most likely etiology of this patient's fetal demise? A. Chronic maternal alcohol use B. Congenital hypothyroidism C. Fetal aneuploidy D. Parvovirus B19 infection E. Rh(D) alloimmunization

D. Parvovirus B19 infection - Hydrops fetalis: skin edema, hepatomegaly, ascites, pleural effusion, pericardial effusion

Which of the following fetal ultrasound findings would be most explained by the presence of Rh disease? A. Meconium B. Fetal bladder obstruction C. Oligohydramnios D. Pericardial effusion E. Placenta previa

D. Pericardial effusion - Fetal hydrops

A 22 year old G1P0 woman at eight weeks getation is noted to have a missed abortion on ultrasound, along with a retroverted uterus. Sh eelcts to undergo suction dilation and curettage. During the procedure, "fatty appearing tissue" is noted to be coming through the curette and her bleeding increased. What is the next best step in management? A. Continue the suction curettage B. Remove the tissue from the curette and replace it into the uterus C. perform an ultrasound D. Proceed with laparoscopy E. Stop the procedure and observe her in the hospital for 48 hours

D. Proceed with laparoscopy - Very concerning for uterine perforation with damage to the omentum and/or bowel - Laparoscopy to examine the bowel closer

A 32 year old woman, G3P3, comes to the office for a 2 week postparum follow-up after undergoing a laparoscopic bilateral tubal ligation. The patient has no pain or abnormal discharge from the incision sites. She has no chronic medical conditions, and this was her only surgery. The patient has a regular menstrual period that occurs every 30 days. She typically has abdominal cramping that resolves with ibuprofen after the first day and 5 days of bleeding. The tubal ligation was succesfully performed, however, during the procedure, multiple subcentimeter superfical lesions were visualized over the broad ligaments, bladder, and sigmoid colon. Biopsy of a lesion reveals endometrial glands, stroma, and hemosiderin-laden macrophages. Which of the following is the best next step in management of this patient? A. Combined OCPs B. CT scan of the abdomen and pelvis C. GnRH agonist therapy D. Reassurance and observation only E. Surgical resection of the lesions

D. Reassurance and observation only - This is describing endometriosis - But she is asymptomatic, so don't need to do anything

A 38 year old woman, G3P3, comes to the office for evaluation of abnormal uterine bleeding. The patient has regular periods until 6 months ago, when she began to have intermenstrual spotting and has now been amenorrheic for 3 months. She has had increased abdominal bloating and cramping during the last few months but no hot flushes or weight changes. The patient has no chronic medical conditions and underwent a bilateral tubal ligation after her last delivery 2 years ago. She takes no daily medications and does not use tobacco, alcohol, or illicit drugs. Blood pressure is 125/70, pulse is 88. BMI is 29. There is coarse hair on the upper lip and bitemporal hair thinning. Examination reveals a large pelvic mass extending throughout the left lower quadrant, but no tenderness or ascites. The cervix appears multiparous with no active bleeding. Urine pregnancy test is negative. Which of the following is the most likely diagnosis? A. Choriocarcinoma B. ovarian thecoma C. Polycystic ovarian syndrome D. Sertoli-Leydig cell tumor E. Struma ovarii teratoma F. Uterine leiomyoma

D. Sertoli-Leydig cell tumor - Increases testosterone and causes symptoms such as voice deepening, male-pattern balding, increased muscle mass, clitoromegaly, oligomenorrhea

A 24 year old woman, G1P1 is evaluated on labor and delivery for heavy vaginal bleeding. Thirty minutes earlier, the patient underwent a forceps-assisted vaginal delivery or a 9 lb male infant at 41 weeks gestation. She feels dizzy and nauseated. The patient has asthma and has had to use her albuterol inhaler frequently throughout her pregnancy. Temp is 97, blood pressure is 104/78, and pulse is 102. O2 sat is 96%. The patient appears pale. The abdomen is soft and nontender and the fundus is boggy and palpable above the umbilicus. Pelvic examination shows an intact perineal repair, no vaginal or cervical lacerations, and profuse vaginal bleeding with passage of large clots. Uterine massage and high-dose oxytocin do not resolve the bleeding. Which of the following is the best next step in management of this patient? A. Broad spectrum antibiotics B. Carboprost tromethamine C. Fresh frozen plasma D. Tranexamic acid E. Vaginal packing with sterile gauze

D. Tranexamic acid - Uterine atony: first line treatment is uterine massage and high-dose oxytocin - If it persists, next best step is tranexamic acid - Carboprost tromethamine is a second-line uterotonic that would come after this - except this patient has asthma and this medication is contraindicated in asthma patients - If medical therapy still doesn't work, she may require fresh frozen plasma

A 37 year old woman comes to the ED for abdominal pain, nausea and vomiting. A week ago, the patient underwent laparoscopic hysterectomy for severe endometriosis, and she went home the next morning. For the past 2 days, the patient has had increasing diffuse abdominal pain and bloating, and she now has nausea and vomiting. She is voiding normally and passing flatus but has noticed increasing vaginal discharge. The patient has no medical conditions and her only other surgeries were 2 C deliveries in her 20s. Temperature is 100.3, blood pressure is 128/72, and pulse is 88. the abdomen is moderately distended but soft and nontender. The laparoscopic incisions are intact and without palpable masses or defect. On pelvic examination there is watery vaginal discharge and the vaginal cuff appears closed. Urinalysis is normal. Abdominal ultrasound reveals a large amount of intraabdominal fluid with no internal echoes. Which of the following is the most likely diagnosis? A. Hemoperitoneum B. Intraabdominal abscess C. Small bowel obstruction D. Unilateral ureteral laceration E. Vaginal cuff dehiscence

D. Unilateral ureteral laceration - Ureter is vulnerable to injury during gynecologic procedures due to its close proximity to the ovarian vessels - The damaged ureter drains directly into the abdomen, resulting in a large volume of intraabdominal fluid and subsequent pain and bloating - As the urine continuously fills the abdomen it can overflow through the vagina and result in a watery vaginal discharge

A 33 year old woman, G2P1, at 29 weeks gestation, comes to the emergency department due to right-sided abdominal pain. The pain developed yesterday morning, initially resolved with acetaminophen, but has become increasingly severe over the past few hours. The patient now has continuous nausea, and has vomited twice. She has not had a bowel movement in 2 days. She has had uterine contractions, but no vaginal bleeding or leakage of fluid. The patient has no chronic medical conditions, and her only surgery was a cesarean delivery for failure to progress. Temp is 99, blood pressure is 130/80, pulse is 118. BMI is 30. Fetal heart rate monitoring shows a baseline of 160/min and no decelerations. Tocodynamometry shows regular uterine contractions every 1-2 minutes. The abdomen is tender to palpation, but has no rebound or guarding. The uterus has fundal tenderness and an associated firm, tender mass. On pelvic examination, the cervix is closed. Leukocyte count is 19,000. Urinalysis is normal. Which of the following is the most likely diagnosis? A. Acute cholecystitis B. Acute diverticulitis C. Acute pyelonephritis D. Uterine fibroid degeneration E. Uterine rupture

D. Uterine fibroid degeneration - Degenerating fibroids can cause uterine contractions, fundal tenderness and a tender mass - Uterine rupture would have an acute abdomen (guarding, rebound tenderness)

A 25 year old G1P1 woman presents to the office with a four month history of a white, watery nipple discharge. She discontinued breastfeeding six months ago. Her last menstrual period was 2 weeks ago. She has been told in the past she had fibrocystic breast changes but otherwise has no significant medical problems or surgical history. A white nipple discharge is noted on manual expression, but the exam is otherwise normal. Serum prolactin level is elevated the same day after exam. What is teh most appropriate next step? A. obtain a brain MRI B. obtain a b-hcg C. begin bromocriptine D. repeat prolactin level e. order a ductogram

D. repeat prolactin level - The manipulation of the breast can cause a falsely elevated level - Repeat when no breast manipulation has been done for at least 24 hours

A 34 year old G2P1 female is at 40 weeks gestation. She was admitted to albor and delivery in active labor 2 hours ago. Her cervix was 4 cm dilated and 100% effaced on admission. Her fetus was vertex and -3 station. you are called to eamine the pateint after she experiences spontaneous rupture of membranes. The cervix is 9 cm dilated, and the fetal head is occiput anterior at 1+ station. You palpate a 5 cm long section of umbilical cord in the patient's vagina. The fetal heart tracing is reassuring. The baseline is 130 bpm. There are multiple accelerations and no decelerations. The patient is having regular uterine contractions every 2 to 3 minutes. She has an epidural and is not feeling the contractions. What is the most appropriate next step in management of this patient? A. Allow for passive descent of the fetal head with continous fetal monitoring B. Have the patient start pushing with the contractions C. Gently attempt to reduce the umbilical cord back up into the uterus D. Perform a forceps assisted vaginal delivery E. Elevate the fetal head with a vaginal hand and perform a Cesarean delivery

E. This is umbilical cord prolapse

A 17 year old G0 sexually active female presents to the emergency department with pelvic pain that began 24 hours ago. She has been experiencing nausea and vomiting and cannot tolerate any oral intake. She reports menarche at the age of 15 and coitarche soon thereafter. She has had four male partners, including her new boyfriend of a few weeks. Her blood pressure is 100/60, pulse 100 and temperature 102.0. On speculum examination, you note a foul-smeeling mucopurulent discharge from her cervical os, and she has significant tenderness with manipulation of her uterus. What is the next best step in the management of this patient? A. Outpatient treatment with oral broad spectrum antibiotics B. Outpatient treatment with intramuscular and oral braod spectum antibiotics C. Intravenous antibiotics and dilation and curettage D. Inpatient treatment, laparoscopy with pelvic lavage E. Inpatient treatment and IV antibiotics

E. Inpatient treatment and IV antibiotics - She has high fever, nausea and vomiting so she requires inpatient admission

Patient admitted with chorioamniotis. 39 weeks. What do you do next? A. Administration of corticosteroids B. Administration of tocolytics C. Cesarean delivery D. Expectant management E. Labor augmentation

E. Labor augmentation - Immediate delivery with augmentation to remove the source of infection

Which of these is the best non-invasive method for detecting fetal anemia? A. Umbilical artery systolic-diastolic ratio B. biophysical profile C. Amniotic fluid index D. Umbilical artery blood flow E. Middle cerebral artery peak systolic velocity

E. Middle cerebral artery peak systolic velocity - This is what is done with the Transcranial Doppler

19 year old G2P1 at 38 weeks gestation comes to the ED with severe abdominal pain and vaginal bleeding. Has not received any prenatal care since 8 weeks for vaginal bleeding. Last pregnancy ended in C section at 24 weeks for placental abruption. Uses cocaine multiple times a week. Blood pressure 90/60 pulse 130. The abdomen is tender and has an irregular mass. Fetal heart tracing shows multiple prolonged decelerations to 100/min. Which of the following risk factors contributed to this patient's presentation? A. First-trimester bleeding B. Illicit substance use C. Interpregnancy interval D. Maternal age E. Prior uterine surgery

E. Prior uterine surgery - This is uterine rupture NOT placental abruption - The irregular mass is protruding fetal parts

A 35 year old nulliparous woman comes to the ED after a syncopal episode while at work as a surgical technician. Her colleagues gave her 1 L normal saline before she arrived. The patient is currently on day 10 of her menses, which have become progressively heavier and longer over the past year, at regular 28-day intervals. ROS is significant for frequent lightheadedness and palpitations. She is sexually active with her boyfriend and takes combined HC. Her temp is 98, blood pressure is 100/60, pulse is 112. Pelvic examination shows an irregularly enlarged uterus 12 weeks in size. Her hemoglobin is 4.9 and MCV is 75. Urine pregnancy test is negative. Which of the following is the most likely cause of this patient's anemia? A. Cyclic bleeding of ectopic endometrial glands B. Endometrial glands within the myometrium C. Endometrial hyperplasia with atypia D. Impaired platelet aggregation E. Proliferation of smooth muscle cells within the myometrium F. Viral infection of the cervical transformation zone

E. Proliferation of smooth muscle cells within the myometrium - These are fibroids - irregular uterine enlargement - B is adenomyosis - regular, enlarged uterus

A 42 year old woman comes to the office due to recurrent abdominal bloating, fatigue, and hot flashes that improve after menses. These symptoms have been occurring for the past 4 days and make her feel "extremely cranky." The patient has missed work due to these symptoms. Her last menstrual period was 3 weeks ago. Menses occur every 30 days for 6 days, with 2 days of heavy flow. She has a history of migraines with aura for which she takes a beta blocker. The patient takes no other medications and has no known drug allergies. She is monogamous with her boyfriend and uses spermicidal foam for birth control. Physical exam is normal. Which of the following is the most appropriate? A. Combined oral contraceptives can improve these symptoms B. FSH levels may reveal the underlying etiology C. Pelvic US is advised to rule out an adnexal mass D. Pregnancy is the most likely cause of these symptoms E. Return to the office in 2 months with a symptom diary

E. Return to the office in 2 months with a symptom diary - PMDD - Symptom diary over 2 menstrual cycles - If symptom pattern consistent with the luteal phase of the menstrual cycle, SSRIs can work - Contraceptives are another option but are contraindicated in this patient due to her migraines with aura

A 62 year old nulligravid woman comes to the office for follow-up after right adnexal enlargement was found on routine pelvic examination 2 weeks ago. Pelvic ultrasound reveals a 5 cm right ovarian cyst. Menopause occurred at age 52 and the patient has had no postmenopausal spotting or bleeding. She had an abnormal Pap test in her 20s that subsequently tested as normal and her medical history is otherwise unremarkable. The patient has never had any surgeries. There is no family history of ovarian or breast cancer. Her most recent mammogram 2 months ago showed no abnormalities. Which of the following is the most appropriate initial course of action for this patient? A. Endometrial biopsy B. Laparoscopy C. Needle aspiration for cytology D. Pap test E. Serum CA-125 level

E. Serum CA-125 level - Ovarian cancer risk increases with age, particularly after menopause - Any ovarian mass in a postmenopausal patient requires investigation

A 30 year old woman, G3P2, at 37 weeks gestation comes to labor and delivery for regular, painful contractions. The contractions started an hour ago and are now 3-4 minutes apart. She has had no leakage of fluid or vaginal bleeding. Fetal movement is normal. At her prenatal visit last week, examination showed a cephalic fetal presentation; group B streptococcus rectovaginal culture was negative. Today, temperature is 98, blood pressure is 110/80, and pulse is 88. Fetal heart rate tracing shows moderate variability, multiple accelerations, and no decelerations. Tocodynamometer shows contractions every 3-4 minutes. The abdomen is nontender when contractions subside. On digital cervical examination, the cervix is 4 cm dilated, 90% effaced, and a taut, bulging bag is palpable with no presenting fetal part. Which of the following is the best next step in management of this patient? A. Amniotomy B. Cesarean delivery C. External cephalic version D. Terbutaline tocolysis E. Transabdominal ultrasound

E. Transabdominal ultrasound - Digital cervical examination is used to determine fetal presentation - If you can't figure it out with the cervical examination (like in this case), you need to do a transabdominal ultrasound to figure it out

A 41 year old nulliparous woman comes to the office due to loss of urine with coughing and sneezing for 4 months. She started wearing a sanitary pad a few days ago due to urine leakage occurring a few times daily. The patient has seasonal allergies and has had frequent coughing and sneezing since the start of the spring season. She takes fexofenadine daily and no other medications. The patient is sexually active with a new partner and uses condoms for contraception. Menses are regular, and her last menstrual period was 2 weeks ago. At age 25, she was treated for chlamydia. She has smoked 10 cigarettes a day since her teens. Her mother has T2DM. The patients' blood pressure is 110/70, BMI is 21. Physical examination shows an irregularly enlarged anteverted and anteflexed uterus. Which of the following would most likely reveal the cause of this patient's urinary symptoms? A. Cystoscopy B. Nucleic acid amplification C. Serum b-HCG D. Speculum examination E. Ultrasonography of the pelvis F. Urinalysis G. Urine culture

E. Ultrasonography of the pelvis - Based on the irregularly enlarged uterus - UTERINE FIBROIDS - Don't be tricked into a pelvic organ prolapse causing this - she hasn't had any children

A 31 year old, G1P0 at 8 weeks gestation comes to the emergency department for persistent nausea, vomiting, epigastric pain and dizziness. The patient has been unable to tolerate any oral intake for the past day. This pregnancy was attained through intrauterine insemination with donor sperm. She has a history of reflux for which she takes an antacid. Prior to pregnancy, the patient drank socially which she stopped before her insemination. Temp is 98, blood pressure 90/50, pulse 114. Her current weight is 121.3 lb, a decrease of 6.6 lb from her prepregnancy weight. Physical examination shows decreased skin turgor and dry mucous membranes. Cardiac examination shows tachycardia but a regular rate and rhythm with no murmurs. The thyroid is non-enlarged and has no palpaable masses. Abdominal examination reveals epigastric tenderness with deep palpation but no rebound, guarding, or palpable masses. A bedside transvaginal ultrasound shows the presence of a 8-week twin intrauterine gestation with 2 normal fetal heartbeats. Which of the following is the next best step in evaluation of this patient? A. A 24-hour urine protein collection B. Quantitative bhCG levels C. Serum T3 and T4 levels D. Upper endoscopy E. Urinalysis for ketones

E. Urinalysis for ketones - This is hyperemesis gravidum - Risk factors include multiple gestations, hydatiditform mole and a history of esophageal reflux - Can be differentiated from typical nausea of pregnancy by the presence of ketones on urinalysis

A 48 year old woman comes to the office due to clear, watery vaginal discharge for the past 2 weeks following a hysterectomy and bilateral SO for endometriosis. Her surgery was complicated by severe pelvic adhesions. The discharge occurs throughout the day and night, and as a result, the patient has been using several pads a day. She has no fever, bleeding or pelvic pain. The patient does not use tobacco, alcohol or drugs. Vital signs are normal. The patient's abdomen is soft and nontender with a well-healed laparotomy incision. Genitourinary examination shows a well-rugated vaginal mucosa and a pool of clear fluid in the vaginal canal. The vaginal apex appears normal. wet mount microscopy shows a few squamous epithelial cells and rare leukocytes. What is the most likely cause? A. Bacterial vaginosis B. Pelvic abscess C. Trichomoniasis D. Vaginal cuff dehiscense E. Vesicovaginal fistula F. Vulvovaginal cadidiasis

E. Vesicovaginal fistula - Remember, this causes urine to leak out of the vagina causing very watery discharge that happens constantly

45 year old woman for well-woman visit. Feels well and has no concerns. Takes a combined OCP and has regular menses. No chronic medical problems. 2 vaginal deliveries in her 30s. Last pap smear with HPV cotesting was normal 5 yeras ago. LMP started 2 days ago. Pelvic exam shows multiparous cervix without lesions. Pap testing reveals benign-appearing endometrial cells and no intraepithelial lesions. What is the next best step? A. Cervical conization B. Colposcopy C. Endometrial biopsy D. Pelvis ultrasound E. Routine Pap testing

E. routine pap testing - Women 45 and over: report endometrial cells cause they could mean something more serious - However, she is asymptomatic, premanopausal and has no risk factors so you don't need to anything about it

A 32 year old woman comes to the ED with abdominal pain that began 2 days earlier but has become increasingly severe over the last 3 hours. The patient has passed several blood clots vaginally for the last hour. She has a history of irregular menstrual cycles and is not sure of the last day of her last period. She was diagnosed with a "heart-shaped uterus" 2 years ago. BMI is 28. Her blood pressure is 90/55, pulse is 120. Abdominal examination shows guarding with decreased bowel sounds. Speculum examination shows moderate vaginal bleeding with clots. A urine pregnancy test is positive. Transvaginal ultrasound shows a gestational sac at the upper left uterine cornu and free fluid in the posterior cul-de-sac. Which of the following is the most appropriate next step in management of this patient? A. Dilation and curettage B. Methotrexate administration C. Misprostol administration D. MRI of the pelvis E. Serum b-hcg level F. Surgical exploration

F. Surgical exploration - She has an acute abdomen (guarding with decreased bowel sounds) likely due to a hemoperitoneum from a rupture ectopic pregnancy