PANCE OB/GYN

36 wks GA fundal height

34 to 38 cm--> Fundal height in an uncomplicated, normal weight pregnancy should be within 1 to 2 cm per week of gestation in pregnancies above 20 weeks

maximum efficacy for her to use emergency contraception

72 hours

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

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

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

The answer is A. EXPLANATION: Primary dysmenorrhea is associated with ovulation, so suppression of ovulation in a woman who no longer desires fertility usually improves symptoms. Narcotics are not indicated as primary treatment in the absence of pathologic disease. Combination oral contraception will suppress ovulation.

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

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

A 17-year-old single female presents to clinic complaining oflower abdominal pain and intermittent dysuria for three days. She is a G0P0, is currently sexually active with one partner, and uses condoms most of the time. She states that she has minimal discharge and no flank tenderness. Vitals are as follows: P 80, BP 120/68, T 98.1F. Abdominal exam is soft and non tender, with no guarding or rebound. A pelvic exam reveals moderate, malodorous, and thin discharge, the cervix is friable, and punctate hemorrhages are noted, uterus midline, mobile no tenderness. Rectal exam is negative. What is the most likely infecting organism? A. Trichomonas vaginalis B. Chlamydia Trachomatis C. Neisseria Gonorrhea D. Candida Albicans E. Gardnerella Vaginalis

The answer is A. EXPLANATION: While all organisms cause cervicitis, punctate hemorrhages (better know as strawberry cervix) is classic for Trichomonas vaginalis. Chlamydia is more commonly asymptomatic in women, GC causes purulent discharge, and candida causes thick, white, and itchy discharge.

A 27-year-old female presents to the office complaining of a lump on one side of her vagina. It has been present for several weeks, and causes only slight discomfort with intercourse. She has no new sexual partners and no other vaginal or systemic symptoms. On physical exam you note a 1.5-cm area of swelling in the left posterior labia majora. It is firm, well circumscribed, and minimally tender, and no changes are noted in the skin. No vaginal discharge or other lesions are noted. What is the most likely diagnosis? A. Vulvar abscessB. Bartholin gland duct cystC. Vulvar lipoma D. AcrochordonE. Lichen planus

The answer is B. EXPLANATION: Bartholin obstruction leads to an asymmetrical posterior labia majora or vestibule, which is not typically painful unless it abscesses. Lipomas are less likely, and lichen planus causes pain and itching without a discrete mass.

You are treating a 21-year-old college student for Trichomonas vaginitis. On exam, she is PMH negative, Social History: + smoking 1ppd, Etoh: 4 x weekly. What is the best option for treatment? A. Metronidazole 2 grams x 1 day B. Metronidazole vaginal gel .75% x 7 days C. Clotrimazole vaginal suppository 100 mg x 7 days D. Betadine douche daily x 7 days E. Doxycycline 100 mg daily x 10 days

The answer is B. EXPLANATION: Clotrimazole, betadine, or doxycycline are not curative for gardnerella. Due to her alcohol intake one would avoid oral metronidazole, due to the antabuse-like reaction that can occur.

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

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

A 51-year-old female presents to the office complaining of intermittent vaginal spotting for three months. She has a history of well-controlled hypertension. She is a nonsmoker. Her LMP was two years ago. Her family history is significant for colon cancer. Physical exam and pelvic exam were performed and unremarkable. What is the best diagnostic step in evaluating her vaginal bleeding? A. Transvaginal ultrasound B. Endometrial sampling C. Pap smear D. Pregnancy test E. STD testing

The answer is B. EXPLANATION: In postmenopausal women with a family history of colon cancer, there is a 30% risk of endometrial cancer. Pregnancy and STD are less likely, and do not exclude endometrial cancer. Pap smear and ultrasound are useful but can be negative. Endometrial sampling is required to confirm or rule out cancer.

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

The answer is B. EXPLANATION: Patients who used assisted reproduction, such as clomiphene, present a special subgroup as their ovaries frequently have ovarian cysts. This is common during the first trimester due to ovarian hyperstimulation. Herpes (A), Cesarean sections (C), and miscarriages (E) are not proven to increase the risk of functional ovarian cysts. A 20-pound unintentional weight loss (D) would have you consider a malignant cause, which is much rarer than a functional ovarian cyst.

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

The answer is B. EXPLANATION: Progesteroneadministration slows GnRH pulses, thereby improving FSH secretion and follicular maturation.

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

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

A 42-year-old woman has experienced recent weight gain, heavy periods, fatigue, cold intolerance, and constipation. She has a rough voice, and her rate of speech is slow. Physical exam is significant for an enlarged thyroid, slow reflexes, and the presence of brittle and coarse hair. She denies any history of bipolar disease or treatment with lithium. Laboratory tests show an elevated TSH and low free T4. What is the most appropriate treatment for this patient? A. propylthiouracil (PTU) B. levothyroxine C. surgical resection D. radioiodide ablation

The answer is B. EXPLANATION: This patient's signs and symptoms are consistent with hypothyroidism. Treatment of choice is levothyroxine, which is partially converted in the body to T3. Significant increases are seen within 1 to 2 weeks, with maximum levels reached in 3 to 4 weeks

A 49-year-old woman has had irregular menses for more than two years. Most of the time she requires only 1-2 mini-pads per day to handle the flow, but recently she soaked through a dozen maxi-pads in a day. On physical examination, she appears well and her pelvic exam in unremarkable. Her serum progesterone is low and her hematocrit is 39%. A transvaginal ultrasound reveals an endometrial stripe of 11 mm. Which of the following is the most appropriate next step in her management? A. Abdominal hysterectomy B. Endometrial biopsy C. Fractional curettage D. Hysteroscopy E. Watchful waiting

The answer is B. EXPLANATION: This woman's excessive bleeding and endometrial stripe > 5 mm raises the suspicion for endometrial hyperplasia or cancer. The next step is an endometrial biopsy, which can be performed without anesthesia in the outpatient setting. Hysterectomy (A) is inappropriate without first establishing a diagnosis for the bleeding. Fractional curettage (C) is the definitive procedure for diagnosis of endometrial carcinoma, but requires anesthesia with its attendant risks. Hysteroscopy (D) is more invasive than endometrial biopsy and may spread tumor cells into the peritoneal cavity. Watchful waiting (E) is inappropriate given with size of the endometrial stripe.

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

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

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

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

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

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

A 26-year-old female presents to clinic complaining of increasing headaches for one year, irritability, bloating and fluid retention, and abdominal discomfort with loose stools during her menstrual cycle. The symptoms begin a day or two before her menses, and last until the middle of her cycle. She has tried acetaminophen and ibuprofen without improvement. On physical exam she is a well-developed, well-nourished female in no acute distress. Vitals are normal, CV and lungs are normal, pelvis exam is normal, pap smear is normal, and GC and Chlamydia testing are negative. What would be the most appropriate next step? A. Pelvic ultrasound B. FSH, LH levels C. Fluoxetine on cycle day 21-7 D. Paroxetine dailyE. Serum HCG

The answer is C. EXPLANATION: Hx and Px are key to diagnosing premenstrual syndrome. Laboratory and radiologic procedures are not useful, particularly in light of a normal exam. With failure of NSAIDS, treatment is aimed at reducing symptoms. For mild to moderate symptoms, SSRI therapy prior to and through the menstrual cycle has become a primary therapy.

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

The answer is C. EXPLANATION: Insertion of a copper-containing IUD is an effective means of preventing an unintended pregnancy in this case. The woman's history of clotting is a contraindication to use of combination oral contraceptives (A). Dilation and curettage (B) is neither appropriate nor effective for emergency contraception. Performing beta hCG determinations (D) would merely detect pregnancy if it were to occur. Given her history of clotting, testing for factor V Leiden (E) may be appropriate but will not affect management at this time.

A 20-year-old woman was just told by her new sexual partner that she needed to be checked for a sexually transmitted infection because he has developed dysuria and a profuse urethral discharge. She herself has had a subjective fever for the past two days, some nausea but no vomiting, diffuse lower abdominal pain, and a severe backache. On examination, she has a temperature of 100.5°F, hypoactive bowel sounds, bilateral lower abdominal quadrant tenderness, a profuse mucopurulent cervical discharge and pronounced cervical motion tenderness. Serum pregnancy testing is negative. She is given an injection of ceftriaxone and a prescription for doxycycline for 14 days and an appointment for follow up the next day. Under which of the following conditions should metronidazole be added to her regimen? A. If she does not appear improved by the following morning B. If she develops vomiting or diarrhea C. If she has a probable tubo-ovarian abscess D. If she has an allergic reaction to the doxycycline E. If she has had more than one partner in the past month

The answer is C. EXPLANATION: Recommended regimens for treatment of pelvic inflammatory disease include ceftriaxone or another parenteral third-generation cephalosporin and doxycycline or cefoxitin, probenecid, and doxycycline. Metronidazole (or clindamycin) should be added to either regimen if a tubo-ovarian abscess is present. If being treated as an outpatient and she has not improved in 3 days (A), or if she develops vomiting (B), she should be hospitalized rather than given metronidazole. Metronidazole is not a satisfactory substitute for doxycycline (D). The patient's condition rather than the number of sexual partners (E) determines the appropriate therapy.

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

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

A 25-year-old woman and her husband have been using condoms and spermicidal foam for the 8 months since the birth of their baby. She plans to wean the baby from the breast sometime between a year and 18 months of age, but would like to begin a "less messy" method of contraception. Prior to her pregnancy she took combination oral contraceptives for several years without any difficulties. Which of the following is an appropriate recommendation for this woman? A. "Breast feeding alone will prevent pregnancy until the baby is weaned." B. "Condoms and spermicide are your only option until you wean the baby." C. "Progestin-only pills are recommended for women who are breast feeding."

The answer is C. EXPLANATION: The progestin-only pill is ideal for breast feeding mothers because this pill does not interfere with lactation the way combination pills do. Breast feeding (A) is reasonably effective in preventing pregnancy only as long as breast milk is the infant's only source of nutrition. Condoms and spermicide (B) are options, but not the only ones for breastfeeding couples. A vaginal ring (D) does decrease the amount of milk production somewhat, but may be an effective option if lactation is well established. Combination oral contraceptives (E) are not recommended for breastfeeding women.

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

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

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

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

A 19-year-old presents complaining of vaginal discharge and itching for 3 days. She is sexually active and uses condoms most of the time. A physical exam reveals the following: vitals are normal, abdomen is soft and non-tender, + bowel sounds, the pelvic exam is notable for moderate discharge with no masses or tenderness. Her wet mount/KOH prep reveals 20 wbcs, 2+ bacteria, no hyphae, 5 to 7 clue cells. What is the most appropriate treatment? A. Terconazole vaginal cream daily x 3 days B. Cefixime 400 mg x one dose C. Ciprofloxin 500 mg BID x 7 days D. Metronidazole 500 mg BID x 7 days E. Azithromycin 1 gram x 1 dose

The answer is D. EXPLANATION: Clues cells with bacteria and white blood cells are indicative of Gardnerella vaginitis, which is best treated with metronidazole.

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

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

A 27-year-old G0P0 woman has been trying to become pregnant for the past 10 months. Menarche occurred at age 13 and her cycles have "always been irregular" except during the 10-year period when she took oral contraceptives. Since stopping contraception two years ago, she and her partner of six years have used condoms consistently until they desired pregnancy. Neither partner has a history of sexually transmitted infection, and both have been mutually monogamous. On physical examination she is 64" tall and weighs 189 pounds. She has increased dark hair on her upper lip and chin and on her lower abdomen and says she has had this hair distribution as long as she can remember. Of the following, what is the most likely cause of her apparent infertility? A. Androgen-secreting ovarian neoplasm B. Hypothyroidism C. Pituitary adenoma D. Polycystic ovarian syndrome E. Premature ovarian failure

The answer is D. EXPLANATION: Patients with polycystic ovarian syndrome typically are obese, infertile, hirsute, and have menstrual disorders, making this the most likely of the diagnoses. An androgen-secreting ovarian neoplasm (A) would cause infertility, but the associated hirsutism is rapidly progressing. Hypothyroidism (B) may cause amenorrhea and weight gain and contribute to infertility, but the overall picture is more suggestive of PCOS. The hyperprolactinemia associated with pituitary adenoma (C) might also produce mild hirsutism, but other symptoms such as galactorrhea would also likely be present. Premature ovarian failure (E) is the spontaneous cessation of menses prior to age 40, and does not apply to this woman.

A 24-year-old female, with a history of type 2 diabetes, presents with the inability to conceive after 14 months of unprotected sexual intercourse with her husband. Vital signs are as follows: Temperature 37° C, BP 115/85, P 65, RR 20. Her BMI is 31. Which physical examination finding would you expect to observe with your suspected diagnosis? A. Undeveloped breasts B. Palpable uterus on abdominal exam C. Acromegaly D. Coarse dark hair on the face, chest, and back E. Egophony on lung exam

The answer is D. EXPLANATION: Polycystic ovarian syndrome (PCOS) affects 5-10% of reproductive age women. It is associated with hirsutism (50% of cases) (D), obesity (80% of cases), and virilization (20%), and those affected have an increased risk of diabetes mellitus, cardiovascular disease, and metabolic syndrome. PCOS patients are often infertile. A palpable ovary may be noted on thin individuals with enlarged ovaries, not the uterus (B). Undeveloped breasts are not a diagnostic indicator for PCOS (A) and acromegaly (C) is seen with Marfan's Syndrome. Egophony (E) is when there is consolidation of the lung on exam.

You are caring for a 29-year-old G1P0 at who is pregnant with twins. She has received routine obstetrical care and her pregnancy has been uneventful to date. What is the average gestation age for twins at delivery? A. 33 to 34 B. 39 to 40 C. 35 to 36 D. 36 to 37 E. 37 to 38

The answer is D. EXPLANATION: The average length of gestation for a single fetus is 40 weeks; the average age of gestation decreases with increasing number of fetuses.

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

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

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

The answer is D. The correct choice is D, serum TSH level. This patient is presenting with post-partum thyroiditis. Thyroid dysfunction occurs in 2 to 5% of women after giving birth. It can recur with subsequent pregnancies and develop into long-term thyroid disease as well. Typically, women with this disorder first develop signs and symptoms of hyperthyroidism, which then later changes to hypothyroidism. Most symptoms resolve spontaneously within a few months. In the hyperthyroid stage of this disorder, blood tests will reveal a suppressed TSH level with elevated serum thyroid hormone levels, as is common in all forms of primary hyperthyroidism. Choice A, a radioactive iodine uptake test, would reveal little or no uptake, but this test should not be ordered in a woman who is breastfeeding. For choice B, a serum total T4 level can be elevated, but is not as sensitive or specific as TSH as a screening test. Any protein status changes in the woman can cause an elevated total T4 without any thyroid dysfunction. Choice C, a thyroid fine needle aspiration, can be performed, but is not likely necessary and would not be the best next step for this patient. Choice E, an MRI of the anterior pituitary, would only be suggested if there is a suspicion of a pituitary tumor. This is a rare cause of hyperthyroidism and would not be the best next step.

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

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

Which of the following would be the best type of exercise to do to strengthen bones and prevent osteoporosis?

Weight training