AMIRICAN BOARD

-11- Consider three 45-year-old patients, all in good health, who are candidates for
these elective or planned procedures:
Patient A: Abdominal hysterectomy
Patient B: Myomectomy
Patient C: Open oophorectomy with salpingectomy
Based solely on the indicated procedure, which patient(s) should receive
perioperative antibiotic prophylaxis in accordance with current ACOG guidelines?
Patient A only

Patient B only

Patients A and B

Patients A and C

Answer: Patient A only. ACOG guidelines recommend antibiotic prophylaxis for

hysterectomy, urogynecologic procedures, hysterosalpingogram, and induced
abortion. These guidelines do not recommend antibiotic prophylaxis for lower-risk
clean procedures, including operative and diagnostic laparoscopy, tubal sterilization,
.hysteroscopy, and laparotomy
Your 63-year-old patient presents with advanced-stage, high-grade epithelial -2
ovarian cancer (EOC). A work-up confirms serous tumor histology. This tumor most
:likely harbors a genetic mutation in
TP53
PTEN
KRAS
BRAF
Answer: TP53. Recent evidence suggests that almost all serous EOC harbors TP53
mutations and are classified as type 2 EOC. In contrast, type 1 tumors usually
present at earlier stages, have a more indolent course, and more commonly carry
other genetic mutations, such as PTEN, KRAS, and BRAF.
3- All of the following structures of the female genital tract are derived from the
Mllerian ducts, EXCEPT:
Ovaries
Fallopian tubes
Uterus
Cervix
Answer: Ovaries. The ovary is derived from multiple embryonic structures, including
the coelomic epithelium, the subcoelomic mesoderm, and the primordial germ cells
from the yolk sac endoderm. The rest of the female genital tract, including the
fallopian tubes, uterus, cervix, and upper vagina, are derived from the Mllerian
ducts.
4- Consider 2 similar patients who previously underwent procedures for pelvic organ
prolapse:
Patient A: Anterior colporrhaphy alone
Patient B: Anterior colporrhaphy with concomitant hysterectomy

Assuming all surgical procedures were performed transvaginally and other factors
are constant, which patient is at the most risk for recurrence of prolapse within 10
years of surgery?
-2Patient A
Patient B
Rates of recurrent prolapse are equal
Not enough information
Answer: Patient A. A study evaluating outcomes of vaginal prolapse surgery among
female Medicare beneficiaries showed that 10 years after surgery, the reoperation
rate was significantly reduced when a concomitant apical suspension procedure was
performed, particularly among women who underwent anterior repair (20.2% vs
11.6%, respectively).
5-Your 30-year-old patient is at 35 weeks' 2 days gestation with a twin pregnancy.
The first twin is in the cephalic presentation. Both fetuses are alive, are of similar size
(estimated weight of 2.2 kg), and are dichorionic and diamniotic. Your patient has no
history of cesarean section. You and your patient decide on a planned vaginal
delivery at 38 weeks' 0 days gestation. Compared with a similar woman scheduled to
undergo a planned cesarean section, you might expect your patient to have:
Increased risk of fetal or neonatal mortality
Decreased risk of fetal or neonatal mortality
Increased risk of birth trauma
No difference in risk of fetal or neonatal death or birth trauma
Answer: No difference in risk of fetal or neonatal death or birth trauma. A
randomized trial, which included >2,800 women, showed that between 32 weeks' 0
days and 38 weeks' 6 days gestation, planned cesarean delivery did not significantly
decrease or increase the risk of fetal or neonatal death or serious neonatal morbidity,
as compared with planned vaginal delivery.
6- Your 28-year-old patient is presenting with a pregnancy of unknown location.
Ultrasonography shows no intrauterine fluid collection and normal adnexa. A single
hCG measurement is 3,000 mIU/mL. Based solely on this information, what is the
most likely diagnosis?

Ectopic pregnancy
Viable intrauterine pregnancy
Nonviable intrauterine pregnancy
Viable or nonviable intrauterine pregnancy
Answer: Nonviable intrauterine pregnancy. In a woman with a pregnancy of
unknown location, no intrauterine fluid collection, normal (or near-normal) adnexa on
ultrasonography, and a single hCG measurement 3,000 mIU/mL indicate that a
viable intrauterine pregnancy is possible but unlikely. The most likely diagnosis is a
nonviable intrauterine pregnancy.
7- Based on the information in the previous question, what is the most appropriate
next step for this patient?
Pharmacologic treatment for ectopic pregnancy
Surgical treatment for ectopic pregnancy
Follow-up hCG measurement
Follow-up hCG measurement and ultrasonogram

Answer: Follow-up hCG measurement and ultrasonogram. Because guidelines

indicate that the most likely diagnosis is a nonviable intrauterine pregnancy, it is
generally appropriate to obtain at least 1 follow-up hCG measurement and
ultrasonogram before initiating treatment for ectopic pregnancy.
-38- Your patient, a 25-year-old Hispanic, has a 5-year history of intravenous opioid
use. At 20 weeks' gestation with her first pregnancy, she decides to enter an inpatient
opioid detoxification program. Which of these factors most strongly influences your
patients likelihood of successful detoxification (defined as no illicit drug use at
delivery)?
Maternal age, ethnicity, or nulliparity
Years of maternal substance use
Intravenous vs intranasal/oral opioids
No maternal factors influence success
Answer: No maternal factors influence success. A retrospective cohort study of 95
women found no maternal demographics or drug histories associated with success,
thus supporting continued opiate detoxification being offered to all women expressing
intent.
Assume your patient was unsuccessful in the detoxification program and was -9
engaging in illicit substance use at the time of delivery. Compared with a similar
woman who had success in the program, your patient is more likely to be
:seropositive for
Hepatitis C virus
HIV
Syphilis
Hepatitis B virus
Answer: Hepatitis C virus. Compared with women who were drug free at the time of
delivery, women with illicit substance use were more likely to test positive for hepatitis
C antibody. HIV, syphilis, and hepatitis B seropositivity did not differ.
:Consider 3 therapies for the treatment of recurrent Clostridium difficile infection-10
Therapy 1: An initial vancomycin regimen (500 mg orally 4 times per day for 4 days),
followed by bowel lavage and subsequent infusion of a solution of donor feces
through a nasoduodenal tube
Therapy 2: A standard vancomycin regimen (500 mg orally 4 times per day for 14
days)
Therapy 3: A standard vancomycin regimen (500 mg orally 4 times per day for 14
days) with bowel lavage
Which therapy has been shown to be most effective in adult patients with a life
expectancy of >3 months and a relapse of C. difficile infection after >1 course of
?adequate antibiotic therapy
Therapy 1
Therapy 2
Therapy 2 and 3 are equally effective
Therapy 1 and 3 are equally effective

Answer: Therapy 1. In a randomized study, the infusion of donor feces was

significantly more effective for the treatment of recurrent C. difficile infection than the
use of vancomycin.
Your 55-year-old patient has urinary stress incontinence, but is ambulatory. To -11
date, she has been using absorbent products to manage her incontinence, but now
desires treatment. Which management strategy do ACOG guidelines advocate as
?first-line treatment for this patient
-4Physiotherapy (eg, pelvic muscle training)
Surgery (eg, midurethral sling)
Pharmacotherapy (eg, oxybutynin, tolterodine)
Mechanical devices (eg, pessaries)
Answer: Physiotherapy (eg, pelvic muscle training). ACOG Practice Bulletin No. 63
states that pelvic floor training, with or without behavioral modifications, appears to
be an effective treatment for adult women with stress and mixed incontinence and
can be recommended as a noninvasive treatment for many women. Pharmacologic
agents may be effective in cases of detrusor overactivity, and surgery is indicated
when conservative treatments have failed to satisfactorily relieve symptoms.
Evidence regarding the effectiveness of mechanical devices is lacking.
Assuming your patients treatment goal is cure, consider 3 initial treatment -12
:scenarios
Treatment A: Physiotherapy alone
Treatment B: Midurethral-sling surgery alone
Treatment C: Physiotherapy followed by midurethral-sling surgery
According to a recent randomized trial, which first-line treatment is most likely to
?achieve your patients goal by 1 year
Treatment A
Treatment B
Treatment C
Treatment B or C
Answer: Treatment B or C. For women with urinary stress incontinence, initial
midurethral-sling surgery, as compared with initial physiotherapy, resulted in higher
rates of subjective improvement and subjective and objective cure at 1 year. Women
who crossed over from the physiotherapy group to the surgery group had outcomes
similar to those of women initially assigned to surgery, and both these groups had
outcomes superior to those women who received physiotherapy alone.
A 30-year-old, African-American patient seeks your advice on reversible -13
contraception. She is a high-school graduate, earns <$800/month, is dependent on
public assistance, and has public insurance. The patient has 1 prior unintended
pregnancy. She is not currently using a contraceptive method, but is sexually active
with a male partner and has no desire to conceive within the next 12 months. Which
?method is this patient most likely to continue using for the next 12 to 24 months
Intrauterine device
Implant
Oral contraceptive pill
Ring or patch

Answer: Intrauterine device. A large cohort study showed that intrauterine devices,
followed by implants, have the highest rates of continuation at 24 months in similar
patients.
All other factors held constant, which method is likely to have the highest rate of -14
continuation at 24 months if your patient is a 24-year-old, Caucasian female who is a
?college graduate who earns $1600/month, has private insurance, and is nulliparous
Intrauterine device or implant
Depot medroxyprogesterone acetate (DMPA)
Oral contraceptive pill
Ring or patch
-5Answer: Intrauterine device or implant. Regardless of potential risk factors for
discontinuation, long-acting reversible contraceptive methods, such as intrauterine
devices and implants, had the highest rates of continuation at 24 months when
compared with shorter-acting methods, such as oral contraceptive pills, patch, ring,
and DMPA.
Among new users in a routine clinical study population, recent evidence suggests -15
that compared with combination oral contraceptive pill use, vaginal ring use is
:associated with higher rates of
Arterial and venous thromboembolism
Venous thromboembolism only
Arterial thromboembolism only
Neither arterial nor venous thromboembolism
Answer: Neither arterial nor venous thromboembolism. A large, prospective,
noninterventional cohort study showed that use of an etonogestrel- and
ethinylestradiol-containing vaginal ring or combination oral contraceptive pills were
associated with a similar venous and arterial thromboembolic risk during routine
clinical use.
:Consider the BRCA mutation status in 3 female patients -16
Patient A: No BRCA mutation
Patient B: BRCA1 mutation carrier
Patient C: BRCA2 mutation carrier
Based solely on this information, which patient has the highest risk of pancreatic
?cancer
Patient A
Patient B
Patient C
Patient B or C
Answer: Patient B or C. A large prospective study showed that
female BRCA1 and BRCA2 mutation carriers have a significantand similar
increased incidence of pancreatic cancer relative to the general population. The 5year survival rate was 5% for patients with a BRCA1 family and 4% for those with
aBRCA2 family.

Assume your female patient carries a mutation in BRCA1. Relative to the general -17
:population, this patients risk of pancreatic cancer is approximately
Equal
Doubled
Tripled
Quadrupled
Answer: Doubled. The risk of pancreatic cancer is approximately doubled in
female BRCA1 and BRCA2carriers.
Your 32-year-old, healthy, premenopausal patient is having symptoms of acute -18
cystitis. Cultures of her voided midstream urine sample show positivity for E. coli,
enterococci, and group B streptococci. Independent of colony counts, which is most
?predictive of bladder bacteriuria in this patient
E. coli only
E. coli and enterococci
E. coli and group B streptococci
-6Enterococci and group B streptococci
Answer: E. coli only. Cultures of voided midstream urine in healthy premenopausal
women with acute uncomplicated cystitis accurately show evidence of bladder E. coli,
but not of enterococci or group B streptococci.
Your patient may carry a higher risk of preterm premature rupture of membranes -19
:(PROM) if she has any of the following, EXCEPT
Intra-amniotic infection
History of preterm PROM
Short cervical length
High BMI
Answer: High BMI. Risk factors for PROM include intra-amniotic infection, a history
of preterm PROM, short cervical length, second-and third-trimester bleeding, low
BMI, low socioeconomic status, cigarette smoking, and illicit drug use.
A patient at 37 weeks' gestation calls your office claiming her water broke. If the -20
patient experienced a premature rupture of membranes, you would expect the pH of
:her vaginal fluid to be approximately
4.9
5.6
7.2
8.0
Answer: 7.2. The diagnosis of membrane rupture may be confirmed by a basic pH
test of vaginal fluid. The normal pH of vaginal secretions is generally 4.5-6.0,
whereas amniotic fluid usually has a pH of 7.1-7.3.
Consider a 36-year-old, anovulatory female who has been diagnosed with -21
abnormal uterine bleeding with ovulatory dysfunction (AUB-O). Endometrial and
structural uterine pathology have been ruled out. What is the most common cause of
?AUB-O in women of this age

Anovulation
Polycystic ovary syndrome
Early menopausal transition
Endometrial hyperplasia
Answer: Polycystic ovary syndrome. Polycystic ovary syndrome is one of the most
common causes of AUB-O in women of reproductive age (aged 19-39 years).
Assuming the patient is hemodynamically stable and has no contraindications for -22
any of the following medical therapies, what is the most appropriate treatment for her
?AUB-O
Therapy A: Low-dose combination hormonal contraceptives
Therapy B: Progestin therapy, including the levonorgestrel IUD
Therapy C: High-dose estrogen
Therapy D: Cyclic hormone therapy
Therapy A only
Therapy A or B
Therapy C only
Therapy B or D
Answer: Therapy A or B. According to the ACOG Practice Bulletin, adolescents (1318 years) with chronic anovulation and women aged 19-39 years generally respond
-7well to low-dose combination hormonal contraceptive therapy or to progestin therapy,
including the levonorgestrel IUD. Patients who are hemodynamically unstable may
benefit from high-dose estrogen therapy.
Assume that this same patient responded well to the levonorgestrel IUD. Is an -23
?endometrial evaluation warranted for her
Yes
No; she is 45 years of age
No; she responded to medical therapy
No; she had a prolonged period of progestin stimulation
Answer: No; she responded to medical therapy. According to the ACOG Practice
Bulletin, patients aged 19-39 years who do not respond to medical therapy or who
have prolonged periods of unopposed estrogen stimulation are candidates for
endometrial assessment. All women >45 years who present with suspected
anovulatory uterine bleeding should undergo endometrial evaluation.
As defined by the US Preventive Services Task Force, current recommendations -24
:for surgical decisions during cesarean delivery favor all of the following, EXCEPT
Pre-skin incision prophylactic antibiotics
Cephalad-caudad blunt uterine extension
Surgeon preference on uterine exteriorization
Manual cervical dilation
Answer: Manual cervical dilation. Recommendations for cesarean delivery with high
levels of certainty favor pre-skin incision prophylactic antibiotics, cephalad-caudad
blunt uterine extension, spontaneous placental removal, surgeon preference on
uterine exteriorization, single-layer uterine closure when future fertility is undesired,
and suture closure of the subcutaneous tissue when thickness is 2 cm. The US

Preventive Services Task Force does not favor manual cervical dilation,
subcutaneous drains, or supplemental oxygen for the reduction of morbidity from
infection.
?Which of the following is sigmoidoscopy associated with -25
Reduced incidence of distal CRC
Reduced incidence of proximal colon cancer
Reduced mortality from proximal colon cancer
Increased likelihood that CRC has microsatellite instability
Answer: Reduced incidence of distal CRC. Sigmoidoscopy is associated with a
reduced incidence of cancer of the distal colorectum and reduced CRC mortality.
Colonoscopy is associated with all of the above, plus a reduced incidence of proximal
colon cancer and reduced mortality from proximal colon cancer. Additionally, CRC
that was diagnosed within 5 years of colonoscopy was more likely than cancer
diagnosed after that period (or without prior endoscopy) to be characterized by the
CpG island methylator phenotype (CIMP) and microsatellite instability.
?What is the most common histologic cell type of endometrial carcinomas-26
Endometrioid
Serous
Clear cell
Squamous
Answer: Endometrioid. Endometrioid adenocarcinoma accounts for >75% of cases.

-8Your patient has endometrial carcinoma of a clear-cell histology. This type of -27
:cancer is often associated with all of the following, EXCEPT
High-grade nuclei
P53 mutation
Prolonged unopposed estrogen stimulation
Polyps
Answer: Prolonged unopposed estrogen stimulation. Endometrial carcinoma of
clear-cell histology is generally of the type II variety, which is associated with highgrade nuclei, P53 tumor suppressor mutation, and endometrial atrophy or polyps.
Type II tumors are not clearly associated with estrogen stimulation.
Consider a 55-year-old patient with stage I endometrial cancer that is confined to -28
the uterine corpus. She underwent primary surgery plus adjuvant vaginal radium
brachytherapy (VBT), followed by subsequent external beam radiation therapy
(EBRT). Based on >20 years of follow-up in the NRH clinical trial, how would you
describe the expected long-term outcomes of this patient, compared to a similar
?patient who received only adjuvant VBT and not EBRT
Increased survival
Decreased risk of secondary cancer
Increased survival and decreased risk of secondary cancer
Decreased survival and increased risk of secondary cancer

Answer: Decreased survival and increased risk of secondary cancer. Long-term

follow-up of patients in the NRH trial showed no survival benefit from subsequent
external pelvic radiation in early-stage endometrial carcinoma. In women <60 years
of age, pelvic radiation decreased survival and increased the risk of secondary
cancer.
:According to a large Danish study, congenital heart defect is most common in -29
Monozygotic twins
Dizygotic twins
All twins
Singletons
Answer: All twins. A study investigating the incidence of congenital heart defect in all
twins and 5% of all singletons born in Denmark between 1977 and 2001 (and
followed through 2006) found that congenital heart defect is more common in twins
than in singletons, and the increased occurrence is not restricted to monozygotic
twins.
A recent study examined the relationship between cervical length and the risk of -30
prematurity in women with low-risk obstetric history. In light of this study, consider 3
:types of patients
Patient A: Parous, with only term births
Patient B: Nulliparous
Patient C: Prior preterm birth
Which patient type is associated with the highest incidence of short cervical length on
?ultrasonography
Patient C
Patient B
Patients B and C are equivalent
-9Patients A, B, and C are equivalent
Answer: Patient C. In this study, a short cervix (15 mm) was identified in <1% of the
low-risk (ie, parous, with only term births) group participants, compared with 3.4%
and 2.1% of the previous preterm birth group participants and nulliparous women,
respectively. Thus, the number needed to screen for short cervical length to prevent
one preterm birth is considerably greater for women who have a low-risk obstetric
history.
A recent study compared antiphospholipid antibodies in maternal sera in -31
deliveries with and without stillbirth. Elevated levels of which of the 2 antibodies
?assayed were associated with increased odds of stillbirth
Anti-2-glycoprotein-1 antibodies
Anticardiolipin antibodies
Both answers are correct
Neither answer is correct
Answer: Both answers are correct. A population-based, case-controlled study
showed that elevated levels of anticardiolipin and anti-2-glycoprotein-1 antibodies
were associated with a 3- to 5-fold increased odds of stillbirth.

In cases of stillbirth, current ACOG guidelines recommend all of the following -32
:maternal tests at time of demise, EXCEPT
Anti-2-glycoprotein-1 antibodies
Anticardiolipin antibodies
Lupus anticoagulant
Human parvovirus B19 antibodies
Answer: Anti-2-glycoprotein-1 antibodies. According to the ACOG Practice Bulletin,
maternal testing for lupus anticoagulant, anticardiolipin antibodies, human parvovirus
B19 IgG and IgM antibodies, and thyroid-stimulating hormone should be conducted
shortly after the diagnosis of stillbirth as these tests may provide information that
could affect the management of future pregnancy.
Use of menopausal hormonal therapy in the United States saw a marked decline -33
following a report from the Womens Health Initiative in 2002. How has this
?influenced incidence rates of breast and ovarian cancer in the US since 2002
Decline in breast cancer only
Decline in ovarian cancer only
Decline in both breast and ovarian cancer
No change in breast or ovarian cancer rates
Answer: Decline in both breast and ovarian cancer. Menopausal hormonal therapy is
associated with increased risk of breast and ovarian cancer, and a reduction in its
use has resulted in accelerated declines of both cancers.
Consider a 28-year-old, African-American female at 8 weeks' gestation with her -34
first pregnancy. Her BMI is 32 kg/m2, with no history of impaired glucose metabolism.
When do the ACOG guidelines recommend that this patient undergo screening via
?the 50-g, 1-hour glucose challenge test
Before 24 weeks only
Before 24 weeks, then if negative, repeated at 24-28 weeks
At 24-28 weeks only
At 24-28 weeks, then if negative, repeated at 32 weeks
-10Answer: Before 24 weeks, then if negative, repeated at 24-28 weeks. Early
screening for detecting gestational diabetes mellitus is suggested in women with
certain risk factors, including a prior history of gestational diabetes, known impaired
glucose metabolism, and obesity (BMI 30 kg/m2).
At 24 weeks' gestation, the patients serum glucose concentration 1 hour after a -35
50-g oral glucose load is 150 mg/dL. As a result, you recommend a 100-g, 3-hour
oral glucose tolerance test (OGTT). Which serum glucose levels for fasting and 1hour, 2-hours, and 3-hours after a 100-g glucose challenge, respectively, fulfill the
?Carpenter and Coustan diagnostic criteria for gestational diabetes mellitus
85 mg/dL; 170 mg/dL; 145 mg/dL; 135 mg/dL
90 mg/dL; 175 mg/dL; 150 mg/dL; 130 mg/dL
95 mg/dL; 190 mg/dL; 165 mg/dL; 140 mg/dL
All of these answers are correct

Answer: 95 mg/dL; 190 mg/dL; 165 mg/dL; 140 mg/dL. Diagnostic criteria for
gestational diabetes mellitus are summarized in this table:

Consider a patient undergoing her first IVF cycle with oocyte donation. You need -36
to decide whether this patient should be placed on bed rest or be allowed to
ambulate immediately following embryo transfer. Based on outcomes from a
randomized, controlled trial, compared with no rest, 10 minutes of bed rest resulted
:in
Worse neonatal characteristics (eg, Apgar score)
Lower live-born infant rates
Lower miscarriage rates
Higher implantation rates
Answer: Lower live-born infant rates. The study showed that, compared with no rest,
10 minutes of bed rest immediate after embryo transfer in patients undergoing IVF
treatment with oocyte donation resulted in significantly lower live-born infant rates
and numerically higher miscarriage rates. Neonatal characteristics (height, weight,
Apgar score) and implantation rates were comparable between the 2 intervention
groups.

-11Assume that the patient in the previous question has a BMI of 30 kg/m2. The -37
recipients obesity is most likely to negatively affect rates of all of the following,
:EXCEPT
Implantation
Miscarriage
Pregnancy
Live birth
Answer: Miscarriage. Rates of the following reproductive outcomes of IVF were
significantly reduced as the BMI of recipients of ovum donation increased:

implantation, pregnancy, clinical pregnancy, twin pregnancy, and live birth. Clinical
miscarriage rates were not influenced by the recipients BMI.
Your 35-year-old, premenopausal, nulliparous patient was just diagnosed with -38
endometrial hyperplasia. She desires fertility preservation and is, therefore, not a
surgical candidate. She has no concurrent or prior diagnosis of breast or ovarian
cancer. You decide to treat with primary progestin therapy and discuss 2 options with
your patient: systemic therapy with oral progesterone and local therapy with the
levonorgestrel-releasing IUD. Compared with systemic therapy, local therapy was
?recently associated with which of the following
Higher rates of complete response
Higher rates of initial response with recurrence
Higher rates of disease persistence or progression
No difference in any outcome over 12 months
Answer: Higher rates of disease persistence or progression. A recent study showed
that outcomes were not significantly different in patients with endometrial hyperplasia
except during the 9- to 12-month assessment: those who had levonorgestrelreleasing IUDs were more likely to have disease persistence or progression
compared with patients who received systemic hormones.
Assume that your patient from the previous question has stage I endometrial -39
adenocarcinoma, rather than hyperplasia. Based on outcomes from the same study,
:compared with systemic therapy, local therapy is associated with higher rates of
Complete response
Initial response with recurrence
Disease persistence or progression
None of these answers is correct
Answer: None of these answers is correct. Outcomes were not significantly different
between the levonorgestrel-releasing IUD and oral progesterone among patients with
cancer at all time points.
A recent study assessed bronchial artery flow-mediated dilation (FMD) as a -40
measure of endothelial function in estrogen-deficient postmenopausal women.
Participants were randomized to receive placebo, oral estradiol (1 mg/d), or
transdermal estradiol (0.05 mg/d) for 12 weeks; treatment continued for an additional
:12 weeks with concurrent endurance exercise training. In this study, FMD increased
In all women at 24 weeks
In estrogen-treated women at 12 weeks only
In estrogen-treated women at 24 weeks only
In estrogen-treated women at 12 and 24 weeks
Answer: In estrogen-treated women at 12 and 24 weeks. FMD significantly
increased in the estrogen-treated groups after 12 weeks, and further increased
-12following 12 weeks of endurance exercise training. FMD remained unchanged in
placebo-treated women at both time points.
A 34-year-old female presents with infrequent menstrual periods and infertility. -41
Her body mass index is 30 kg/m2, and acne and hirsutism are apparent on physical
exam. Based on these findings, you immediately suspect polycystic ovary syndrome

(PCOS). Excluding other possible etiologies, does this patient meet the diagnostic
?criteria for PCOS
Yes, the Rotterdam criteria
Yes, the Androgen Excess Society (AES) criteria
Yes, both the Rotterdam and AES criteria
No
Answer: Yes, both the Rotterdam and AES criteria. Based on the presence of
stigmata of hyperandrogenism (eg, hirsutism) and oligomenorrhea, this patient meets
the recommended diagnostic criteria for PCOS by 3 expert groups: NIH, Rotterdam,
and the AES. Note that the Rotterdam and AES Criteria include not only
hyperandrogenism and oligomenorrhea/amenorrhea but also polycystic ovaries by
ultrasound diagnosis in their diagnostic schemes.
Assume that you confirm a diagnosis of PCOS in this patient and that she is not -42
attempting to conceive. Based solely on this information and current ACOG
guidelines, which of these represents 1 possible medical maintenance therapy to
?reduce the risks of cardiovascular disease and diabetes in this patient
Aromatase inhibitors
Gonadotropins
Clomiphene citrate
Statins
Answer: Statins. According to the ACOG Practice Bulletin, statins, along with lifestyle
modification, insulin-sensitizing agents, and combined hormonal contraceptives and
progestins, are options for medical maintenance therapy to reduce the risks of
cardiovascular disease and diabetes in women with PCOS who are not attempting to
conceive. Clomiphene, gonadotropins, and aromatase inhibitors may be considered
as ovulation induction methods in women with PCOS who are attempting to
conceive.
Assume that your patient with PCOS has been treated with atorvastatin, 20 mg/d -43
for 6 months. Based on recent literature, statin therapy has been shown to improve
:all of the following, EXCEPT
Chronic inflammation
Lipid profile
Insulin sensitivity
Serum dehydroepiandrosterone sulfate (DHEAS) levels
Answer: Insulin sensitivity. A randomized, controlled study conducted in Finland
showed that in women with PCOS, atorvastatin therapy improved chronic
inflammation and lipid profile, but impaired insulin sensitivity during 6 months of
atorvastatin therapy. Statin use was also associated with decreased serum DHEAS
levels and no change in serum testosterone levels.
Consider, instead, that your patient with PCOS wants to conceive and -44
undergoes several methods of ovulation induction, but eventually becomes pregnant
following non-donor-assisted in vitro fertilization. Based on results from a large,
population-based linkage study conducted in Britain, her child may have an
:increased risk of
-13Leukemia

Retinoblastoma
Hepatoblastoma
Central nervous system tumors
Answer: Hepatoblastoma. In a cohort of >100,000 British children born after nondonor-assisted conception, there was no increase in the overall risk of cancer or in
the risk of leukemia, neuroblastoma, retinoblastoma, central nervous system tumors,
or renal or germ-cell tumors. However, non-donor-assisted conception was
associated with an increased risk of hepatoblastoma and rhabdomyosarcoma.
Her child was the result of a singleton birth, born at 33 weeks' gestation and -45
weighed <2.5 kg at birth. In the same study of cancer risk among children born after
assisted conception, which of these factors was shown to be associated with
?increased hepatoblastoma risk
Singleton birth
Gestational age 32-36 weeks at birth
Low birth weight
Parental age
Answer: Low birth weight. The excess risk of hepatoblastoma was associated with
birth weight <2.5 kg.
Your patient is a 28-year-old female. Two years ago, her first child was born at -46
26 weeks' gestation. She is currently at 21 weeks' 2 days gestation with her second
singleton pregnancy. In anticipation of another preterm birth, she asks you about the
likelihood of her childs survival. You tell her that, based on scientific evidence, there
are percentage rates correlating to an infant born at 21 weeks' and 25 weeks'
:gestation living to at least 4 months. They are, respectively
0%; 75%
10%; 85%
0%; 65%
10%; 70%
Answer: 0%; 75%. According to the ACOG Practice Bulletin, parents of anticipated
preterm fetuses can be counseled that the neonatal survival rate for newborns
increases from 0% at 21 weeks' gestation to 75% at 25 weeks' gestation.
The patient in the previous question gives birth to a son at 24 weeks' 5 days -47
gestation. At birth, the male infant weighs 700 g. Based on current evidence, this
infant has a predicted survival rate of about 50%. Assuming similar gestational age
and weight, how would you expect the newborns predicted survival rate to change if
?your patient had given birth to a female instead of a male
Increase
Decrease
No change
Not enough information
Answer: Increase. When comparing infants of similar gestational age and weight,
survival rates are higher for females than for males. For example, a male born at 24
weeks' gestation at a weight of 700 g has a predicted survival rate of 49%, whereas a
female of the same age and weight has a predicted survival rate of 65%.
Your patients extremely preterm son is now 18 months old (corrected age) and is -48
undergoing his routine neurologic examination. According to ACOG, all of the

following are considered significant risk factors for cerebral palsy in extremely low:birth-weight infants evaluated at this age, EXCEPT
-14Grade III-IV intraventricular hemorrhage
Periventricular leukomalacia
Necrotizing enterocolitis
Use of postnatal steroids
Answer: Use of postnatal steroids. According to the ACOG Practice Bulletin,
significant risk factors for cerebral palsy in extremely low-birth-weight newborns
evaluated at 18 to 22 months (corrected age) include: grade III-IV intraventricular
hemorrhage, periventricular leukomalacia, and necrotizing enterocolitis. These 3
factors, in addition to use of postnatal steroids, chronic lung disease, a mother with
less than a high school education, and male sex of the fetus, are risk factors for
abnormal neurologic examination or Mental Development Index or Psychomotor
Developmental Index scores <70.
A whole-exome sequence analysis of a large consanguineous family with -49
inherited premature ovarian failure identified a mutation in STAG3. According to the
study, Stag3 null mice are sterile and their fetal oocytes are arrested at early
prophase I, leading to oocyte depletion at 1 week of age. What does the product
?of STAG3 have a role in
Sister chromatid cohesion
Spindle formation
Homologous recombination
Nuclear envelope formation
Answer: Sister chromatid cohesion. Mammalian STAG3 encodes a meiosis-specific
subunit of the cohesin ring, which ensures correct sister chromatid cohesion.
Compared with routine care, blastocyst biopsy with embryonic aneuploidy -50
screening has been shown to significantly improve which in vitro fertilization
?outcome(s)
Implantation rates
Delivery rates
Both implantation and delivery rates
Neither implantation nor delivery rates
Answer: Both implantation and delivery rates. A randomized, controlled trial of
infertile couples who are attempting conception through IVF showed that blastocyst
biopsy and rapid quantitative real-time polymerase chain reaction (qPCR)based
comprehensive chromosome screening significantly improved IVF outcomes, as
measured by meaningful increases in sustained implantation and delivery rates.
Consider 3 patients, all 27-year-old females, with a history of human -51
papillomavirus (HPV) infection, cervical dysplasia, and the following cytology test
:results
Patient A: Atypical squamous cells of undetermined significance (ASC-US)
Patient B: High-grade squamous intraepithelial lesion (HSIL)
Patient C: Low-grade squamous intraepithelial lesion (LSIL)
Based solely on these cytology results and current ACOG guidelines, the loop

electrosurgical excision procedure (LEEP) is an acceptable management strategy in

?which patient(s)
Patient A only
Patient B only
Patients A and B
-15Patients A and C
Answer: Patient B only. According to the ACOG Practice Bulletin, immediate LEEP
or colposcopy is acceptable for women with HSIL cytology test results, except in
special populations. In particular, a diagnostic excisional procedure is recommended
in this setting when the colposcopic examination is inadequate, except during
pregnancy.
Assume that the patient with HSIL cytology underwent LEEP. Ten months -52
following the procedure, she becomes pregnant. In general, how does the risk for
preterm birth (before 37 weeks' gestation) in this patient compare with that for a
?similar patient with prior cervical dysplasia but no cervical excision
Increased risk
Decreased risk
Similar risk
Not enough evidence
Answer: Similar risk. A recent meta-analysis did show that LEEP was associated
with an increased risk of preterm birth. However, no increased risk was found when
women with a history of LEEP were compared with women with a history of dysplasia
but no cervical excision. Therefore, common risk factors for both preterm birth and
dysplasia likely explain the association between LEEP and preterm birth.
The patient in the previous question became pregnant <12 months following -53
LEEP. This short time interval from LEEP to pregnancy has been associated with
?which of the following
Increased risk for extremely preterm birth (<34 weeks of gestation)
Increased risk for spontaneous abortion
Increased risk for spontaneous abortion and extremely preterm birth
Decreased risk for extremely preterm birth
Answer: Increased risk for spontaneous abortion. According to a 10-year, multicenter
cohort study, women with a shorter time interval, specifically <12 months, from LEEP
to pregnancy are at increased risk for spontaneous abortion, but not preterm birth.
:Consider 3 female candidates for in vitro fertilization (IVF) -54
Patient A: 34-year-old with favorable IVF prognosis
Patient B: 37-year-old with average IVF prognosis
Patient C: 32-year-old with less favorable IVF prognosis
Based solely on this information, in which patient should you consider transferring
only 1, rather than 2, day 3 or day 5 fresh embryos for the highest chances of
?achieving a term, normalbirth-weight singleton
Patient A only
Patient B only

Patients A and B
Patients A and C
Answer: Patient A only. In a large study conducted by the National ART Surveillance
System Group, patients <35 years of age undergoing IVF with a favorable prognosis
had the highest chance of good perinatal outcome (defined as birth of a term,
normalbirth-weight singleton) with a single, rather than double, fresh embryo
transfer. Among patients aged 40 years with an average prognosis, or patients aged
-16<35 years with a less favorable prognosis, a higher chance of good perinatal
outcome was associated with transferring 2 (compared with 1) day 3 embryos.
Compared with pregnant women of normal weight, women who are obese when -55
they become pregnant are more likely to experience which type of depression
?symptoms
Elevated antenatal and postpartum
Elevated antenatal
Elevated postpartum
Similar antenatal and postpartum
Answer: Elevated antenatal and postpartum. A meta-analysis including >500,000
women found that obese and overweight women were significantly more likely to
experience elevated depression symptoms both during and after pregnancy than
normal-weight women, with intermediate risks for overweight women.
:Regarding the physiology of lactation, infant suckling stimulates the release of -56
Prolactin and oxytocin
Progesterone and oxytocin
Cortisol and progesterone
Prolactin and cortisol
Answer: Prolactin and oxytocin. During pregnancy, placental progesterone blocks
milk synthesis. After birth, falling progesterone levels trigger onset of milk production.
Infant suckling stimulates the release of prolactin and oxytocin, which regulate milk
synthesis and milk secretion. Cortisol, thyroid hormone, insulin, and growth hormone
further support milk synthesis.
Your 33-year-old patient is pregnant with her first child. Her pre-pregnancy BMI -57
is 26 kg/m2. She has no history of diabetes or hypertension. However, she was
diagnosed with gestational diabetes mellitus (GDM) by routine 75-g oral glucose
tolerance test at 24 weeks' gestation. Does this diagnosis put her at higher risk for
?sleep-disordered breathing
Yes, because her prepregnancy BMI is <35 kg/m2
Yes, because she has no history of diabetes
Yes, because she has no history of hypertension
No
Answer: No. A recent case-control study found no association between GDM and
sleep-disordered breathing in pregnant women with pre-pregnancy BMIs <35
kg/m2 and no medical comorbidities.
:Consider 3 female adolescents with the following characteristics -58

Patient A: Hispanic; first sexual partner >6 years older; lives with grandmother
Patient B: Black, non-Hispanic; no religious affiliation; no contraception use at sexual
debut
Patient C: Asian; first sexual partner 2 years older; Protestant religious affiliation
Based solely on this information, which patient is most likely to become pregnant
?before age 15 years
Patient A only
Patient B only
Patients A and B
Patients B and C
-17Answer: Patients A and B. An analysis of data from the National Survey of Family
Growth reported that women with pregnancies before age 15 years were more likely
to be Hispanic or black; to report that their first sexual partner was >6 years older;
and to report that the index of pregnancy was unintended. They were less likely to
report being raised within a religion; living with both biological parents at age 14
years; and using contraception at sexual debut
Your patient, a 54-year-old, healthy, menopausal woman with prior hysterectomy, -59
is seeking relief from hot flashes. Current opinion, based on findings from the
Womens Health Initiative trials, suggests that menopausal hormone therapy may be
an appropriate strategy for the treatment of moderate-to-severe vasomotor
?symptoms in similar patients if it is initiated within how many years of menopause
10
20
15
5
Answer: 10. Data from the Womens Health Initiative trials suggest that short-term
hormone therapy (<5 years for most women) can be used for treatment of moderateto-severe vasomotor symptoms in healthy women soon after menopause (<10 years
from menopause onset).
Your patient in the previous question is concerned about the side effects of -60
hormone therapy and would like to consider an alternative for the management of her
menopausal symptoms. What is the only nonhormonal therapy that is FDA-approved
?for the treatment of vasomotor symptoms
Paroxetine
Ospemifene
Clonidine
Gabapentin
Answer: Paroxetine. The FDA approved ospemifene for treating moderate-to-severe
dyspareunia in postmenopausal women.
Which of these has NOT been identified as a common risk factor for -61
?breastfeeding difficulties
Widely spaced, tubular breasts
Macromastia

History of breast reduction/augmentation

Excessive glandular tissue
Answer: Excessive glandular tissue. Risk factors for breastfeeding difficulties can
include widely spaced, tubular breasts, which may indicate insufficient glandular
tissue; macromastia; and a history of breast reduction or breast augmentation.
Your patient, a 32-year-old, normal-weight female, recently gave birth via vaginal -62
delivery. At birth, the infant weighed 3 kg with a head circumference of 33.4 cm. At
her 6-week postpartum check-up, the patient queries you about her urinary
incontinence. You tell her that, while each patient is different, recent data suggest
that urinary incontinence does not typically interfere with daily life after how many
?weeks postpartum
6 weeks
4 months
6 months
12 months
-18Answer: 6 weeks. A prospective, longitudinal study showed that vaginal delivery was
associated with higher urinary incontinence prevalence, but there was no association
with interference in daily life after 6 weeks' postpartum.
Your patient in the previous question asks whether she is more likely to -63
experience urinary incontinence because she had a vaginal delivery rather than a
cesarean delivery. Based on recent literature, what is the most reasonable answer to
?her question
No, equally as likely
Yes, about twice as likely
Yes, about four times as likely
No, less likely
Answer: Yes, about twice as likely. The same study showed that, compared with
cesarean delivery, vaginal delivery was associated with an approximately 2-fold
higher prevalence of any urinary incontinence at 4-6 weeks and at 3, 6, and 12
months: 29.140.2% vaginal vs. 14.225.5% cesarean.
Assume that a candidate for medical abortion is scheduled to undergo the -64
procedure at 40 days' gestation. Which common regimen(s) offer(s) a >90% overall
success rate, with relatively fewer adverse events, relatively low drug cost, and no
?return office visit necessary for administration
Regimen A: Mifepristone 600 mg orally, followed by misoprostol 400 mcg orally 48
hours later
Regimen B: Mifepristone 200 mg orally, followed by misoprostol 800 mcg vaginally,
buccally, or sublingually 2448 hours later
Regimen C: Methotrexate 50 mg vaginally, followed by misoprostol 800 mcg
vaginally 37 days later
Regimen D: Misoprostol only, 800 mcg vaginally or sublingually every 3 hours for 3
doses
Regimens A or C
Regimen B only
Regimens B or C

Regimens B or D
Answer: Regimens B or C. These two common medical abortion regimens are
collectively associated with a 92%99% overall success rate, fewer adverse effects
than the FDA-approved or misoprostol-only regimens, relatively low drug cost, and
no need to return to the office or clinic for misoprostol administration. According to
the ACOG Practice Bulletin, women can safely and effectively self-administer
misoprostol at home as part of a medical abortion regimen.
How would your answer to the previous question change if the patient was -65
?scheduled to undergo medical abortion at 56 days' gestation
Regimen A: Mifepristone 600 mg orally, followed by misoprostol 400 mcg orally 48
hours later
Regimen B: Mifepristone 200 mg orally, followed by misoprostol 800 mcg vaginally,
buccally, or sublingually 2448 hours later
Regimen C: Methotrexate 50 mg vaginally, followed by misoprostol 800 mcg
vaginally 37 days later
Regimen D: Misoprostol only, 800 mcg vaginally or sublingually every 3 hours for 3
doses
-19Regimens A or C
Regimen B only
Regimens B or C
Regimens B or D
Answer: Regimen B only. Methotrexate in combination with misoprostol has shown
efficacy up to 49 days' gestation, whereas mifepristone plus misoprostol administered
by a nonoral route has high complete abortion rates up to 63 days' gestation. Vaginal,
buccal, and sublingual routes of misoprostol administration increase the gestational
age range for use as compared with the FDA-approved regimen.
You are considering the initiation of androgen therapyoff-label transdermal -66
testosteronefor the treatment of hypoactive sexual desire disorder in your
postmenopausal patient. Based on available evidence, what is the maximum
?recommended duration of transdermal testosterone use in this setting
2 months
6 months
1 year
2 years
Answer: 6 months. Transdermal testosterone has been shown to be effective for the
short-term treatment of hypoactive sexual desire disorder in women, with little
evidence to support long-term use (>6 months).
Which class of medications is most commonly linked to female sexual -67
dysfunction, including orgasmic dysfunction, decreased sexual desire, and
?decreased arousal
Selective serotonin reuptake inhibitors (SSRIs)
Oral contraceptives
Corticosteroids
Antihypertensives

Answer: Selective serotonin reuptake inhibitors (SSRIs). The most frequently

reported problems are hypoactive sexual desire disorder, sexual arousal disorder,
and orgasmic dysfunction.
To reduce the incidence of breast cancer mortality, at what age should women -68
?start getting mammograms and how often should this be offered
40; annually
40; biennially
50; annually
50; biennially
Answer: 40; annually. ACOG, the American Cancer Society, and the National
Comprehensive Cancer Network all recommend annual mammography screening
beginning at age 40 years. The US Preventive Services Task Force recently changed
its guidelines to recommend biennial mammography in women aged 5074 years
and suggested that screening be conducted on a case-by-case basis in women <50
years.
Consider a pregnant woman who is heterozygous for the factor V Leiden -69
mutation. Her family history consists of an affected first-degree relative with a
thrombotic episode before age 50 years; she has no personal history of venous
thromboembolism. Antepartum management consisted of surveillance without
-20anticoagulation therapy. You determine that postpartum anticoagulation therapy is
necessary following delivery. Which anticoagulation therapy may be used if the
?patient plans to breastfeed
Warfarin only
Lowmolecular-weight or unfractionated heparin only
Unfractionated heparin only
Warfarin or lowmolecular-weight heparin or unfractionated heparin
Answer: Warfarin or lowmolecular-weight heparin or unfractionated heparin.
Warfarin, lowmolecular-weight heparin, and unfractionated heparin do not
accumulate in breast milk and do not induce an anticoagulant effect in the infant;
therefore, these anticoagulants may be used in women who breastfeed.
Your patient has continued tobacco and alcohol abuse during pregnancy. Based -70
on prenatal screening, delivery for fetal growth restriction is anticipated at 33 weeks'
gestation. According to ACOG guidelines, administration of which of the following is
?recommended before delivery
Corticosteroids
Magnesium sulfate
Both corticosteroids and magnesium sulfate
Neither corticosteroids nor magnesium sulfate
Answer: Corticosteroids. When delivery for fetal growth restriction is anticipated
before 34 weeks' gestation, antenatal corticosteroids should be administered before
delivery because they are associated with improved preterm neonatal outcomes. For
cases in which delivery occurs before 32 weeks' gestation, magnesium sulfate
should be considered for fetal and neonatal neuroprotection.

Cesarean birth rates have rapidly increased from 1996 to 2011. Which -71
indications most strongly contributed to this increase, accounting for >50% of all
?primary cesarean deliveries in the US in 2011
Labor dystocia and abnormal/indeterminate fetal heart rate tracing
Suspected fetal macrosomia and multiple gestation
Fetal malpresenation and maternal request
Multiple gestation and preeclampsia
Answer: Labor dystocia and abnormal/indeterminate fetal heart rate tracing.
According to a 2011 population-based study, arrest of labor and abnormal or
indeterminate fetal heart rate tracing were the most frequent indications and
accounted for more than one-half of all primary cesarean deliveries in the study
population.
Assume a multiparous woman is in her first stage of labor. According to the most -72
recent Obstetric Care Consensus and data from the Consortium on Safe Labor,
active phase protraction or labor arrest should not be diagnosed in this patient before
?how many centimeters of dilation
6 cm
4 cm
5 cm
7 cm
Answer: 6 cm. Because the active phase of contemporary labor does not typically
start until at least 6 cm regardless of parity, the Consortium on Safe Labor suggests
that diagnosis of labor dystocia not be diagnosed before that point.
-21Consider 3 similar female patients in the first stage of labor, each with a different -73
:parity
Patient A: Parity 0
Patient B: Parity 1
Patient C: Parity 2
Based on contemporary data from the Consortium on Safe Labor, which patient
?would you expect to progress most quickly from 4 to 6 cm of dilation
Patient B
Patient C
Patients B and C progress at the same rate
Patients A, B, and C progress at the same rate
Answer: Patients A, B, and C progress at the same rate. Contemporary data suggest
that from 4 to 6 cm, nulliparous and multiparous women dilate at essentially the same
rate. Beyond 6 cm, multiparous women dilate more rapidly.
You determine that hysterectomy is indicated for your patient with symptomatic -74
?uterine fibroids. Which procedure does the FDA discourage in this setting
Traditional vaginal hysterectomy
Laparoscopic hysterectomy with morcellation
Traditional abdominal hysterectomy

Minilaparotomy hysterectomy
Answer: Laparoscopic hysterectomy with morcellation. Use of laparoscopic power
morcellation for the treatment of symptomatic uterine fibroids poses a risk of
spreading unsuspected cancerous tissue, notably uterine sarcomas, beyond the
uterus. Because there is no reliable method for predicting whether a woman with
fibroids may have a uterine sarcoma, the FDA discourages use of laparoscopic
power morcellation during hysterectomy or myomectomy for uterine fibroids. All other
available treatment options should be carefully considered in this setting.
:Consider 3 women with current singleton pregnancies -75
Patient A: History of one second-trimester pregnancy loss related to painless cervical
dilation and in the absence of labor or abruptio placentae
Patient B: Presents with painless cervical dilation in the second trimester on physical
examination
Patient C: Presents with cervical length <25 mm on ultrasound before 24 weeks'
gestation; nulliparous
Based solely on this information and current ACOG guidelines, in which patient is
?cerclage placement an appropriate management strategy
Patient A only
Patients A and B
Patient C only
Patients A, B, and C
Answer: Patients A and B. According to the ACOG Practice Bulletin, cerclage
placement may be indicated based on a history of cervical insufficiency, physical
examination findings, or a history of preterm birth and ultrasonographic findings of
short cervical length before 24 weeks' gestation.
When is the ultrasonographic finding of short cervical length in the second -76
?trimester sufficient for the diagnosis of cervical insufficiency
-22Always
Never
In patients with a history of singleton preterm birth
In nulliparous women
Answer: Never. According to the ACOG Practice Bulletin, the ultrasonographic
finding of a short cervical length in the second trimester is associated with an
increased risk of preterm birth, but is not sufficient for the diagnosis of cervical
insufficiency. However, cerclage may be effective in particular circumstances when a
short cervix is found, such as in women with a history of spontaneous preterm birth at
<34 weeks' gestation.
A 16-year-old female is frantic because her boyfriend just confessed that the -77
condom broke during their previous act of sexual intercourse, which occurred 4 days
ago. She comes to your office seeking emergency contraception. Is she too late for a
?levonorgestrel-only regimen to be effective
Yes; regimens are effective up to 24 hours after intercourse
Yes; regimens are effective up to 3 days after intercourse
No; regimens are effective up to 4 days after intercourse
No; regimens are effective up to 5 days after intercourse

Answer: No; regimens are effective up to 5 days after intercourse. According to the
ACOG Practice Bulletin, the currently available levonorgestrel-only emergency
contraception regimens are effective and should be made available to patients who
request it up to 5 days after unprotected intercourse.
The same patient is relieved to learn that emergency contraception is still an -78
option, but wants to be certain this option is not the same thing as a medical abortion.
You assure her that, unlike an abortion, emergency contraception is only effective
before a pregnancy is established. You continue to educate her on the way
emergency contraception works. What best describes the established mechanism of
?action for levonorgestrel-only emergency contraception
Inhibits or delays ovulation
Alters endometrium to inhibit implantation of a fertilized egg
Interferes with sperm transport or penetration
Varies according to the day of the menstrual cycle
Answer: Varies according to the day of the menstrual cycle. Although several modes
of action for emergency contraception have been proposed, no single mechanism
has been established. The mode of action varies according to the day of the
menstrual cycle on which intercourse occurs and emergency contraception is
administered.
The patient is able to fill her prescription for the 2-dose, levonorgestrel-only -79
regimen (2 tablets, each containing 0.75 mg levonorgestrel). She takes the first pill
immediatelyat 4pm. At 8am the next morning, she calls your office because she
slept through her 4am alarm and failed to take the second pill 12 hours after the first
dose. What is her best course of action to ensure effective emergency
?contraception
Take the second 0.75-mg levonorgestrel dose before 4pm
Get a new prescription for the 1.5-mg levonorgestrel-only regimen
She has no further options for emergency contraception
Consider an alternative emergency contraception method
Answer: Take the second 0.75-mg levonorgestrel dose before 4pm. Though the 2dose, levonorgestrel-only regimen instructs patients to take one 0.75-mg pill as soon
-23as possible after unprotected intercourse and to take the second 0.75-mg pill 12
hours after the first dose, the 2 doses are equally effective if taken 12 to 24 hours
apart.
Consider 3 pregnant women at 34 weeks' gestation who have had 2 cervical -80
:examinations
Patient A: Current singleton pregnancy
Patient B: Nulliparous with current twin pregnancy
Patient C: Multiparous with current twin pregnancy
Assuming that the women carry healthy fetuses, the presenting twin is in the cephalic
presentation in the twin gestations, and all other factors are controlled, which patient
?would you expect to have the fastest progression of active-phase labor
Patient A
Patient B

Patient C
Patients B or C
Answer: Patient A. A large retrospective study of women meeting criteria similar to
these 3 patients found that both nulliparous and multiparous women have slower
progression of active phase labor with twins vs singletons, even when controlling for
confounding factors.
Remodeling and repair of bone during adulthood are accomplished through -81
resorption and formation processes. How many years before the final menses does
?the most rapid period of bone loss in women occur
1 year
2 years
3 years
It occurs 1 year after final menses
Answer: 1 year. Remodeling and repair of bone during adulthood are accomplished
through resorption and formation processes controlled by osteoclasts (resorption)
and osteoblasts (formation). The ACOG Practice Bulletin reports that the time of most
rapid bone lossbeginning 1 year before final menses and lasting 3 years
coincides with the marked decline in estrogen levels associated with menopause.
Consider 2 Caucasian, postmenopausal females who have similar bone mineral -82
densities: one is 60 years old; the other is 70. Compared with the 60-year-old
?woman, what increased risk of osteoporotic fracture does the 70-year-old have
2-fold
5-fold
10-fold
20-fold
Answer: 10-fold. A recent study that evaluated osteoporotic fracture risk-prediction
models in >600 women found that compared with postmenopausal women <65
years, the odds ratio of fractures in women 65 years was 10.2. Age alone was a
significant predictor for fracture and improved the predictive value of each model
tested.
You are responsible for diagnosing suspected osteoporosis in the 70-year-old -83
postmenopausal woman mentioned in the previous question. After BMD
measurement of the patients femoral neck, total hip, and lumbar spine, her T-score
?is -2.2. Based on this score and the WHO criteria, what is your diagnosis
-24Normal
Low bone mass (osteopenia)
Osteoporosis
Not enough information
Answer: Low bone mass (osteopenia). In postmenopausal women, only the T-score
is used for the purpose of diagnosing osteoporosis. The T-score categories are
normal, low bone mass (formerly called osteopenia), and osteoporosis, as shown in
this table. A T-score -2.5 at either the femoral neck, total hip, or lumbar spine

establishes the diagnosis of osteoporosis.

Your patient is a 25-year-old female with AIDS. She is clinically well while taking -84
a ritonavir-boosted protease inhibitor. According to current ACOG management
guidelines, what is the most appropriate and effective method of contraception for
?this patient
Copper IUD
Combined oral hormonal contraceptive
Combined non-oral hormonal contraceptive (ie, patch, ring)
Progestogen-only pill
Answer: Copper IUD. Because hormonal contraceptives are primarily metabolized
via sulphate and glucoronide conjunction in the liver and also via cytochrome P450,
there are concerns regarding the efficacy of hormonal contraception in women using
HAART. For example, ritonavir, nelfinavir, and lopinavir cause a 40%50% decrease
in ethinyl estradiol levels; therefore, combined oral contraceptives generally are not
recommended for women taking regimens containing these antivirals. Additionally, for
women using ritonavir-boosted protease inhibitors, the risks of a progestogen-only
pill usually outweigh the advantages. Current evidence suggests that the copper and
levonorgestrel-containing IUDs may be used for women with AIDS who are clinically
well while taking HAART.
?ACOG recommends routine HIV screening of women in which age range -85
1964 years
1540 years
1759 years
2169 years
Answer: 1964 years. ACOG recommends routine HIV screening of women aged
1964 years and targeted screening for women outside of that age range with risk
factors.
What best describes the mechanism of infertility associated with early-stage -86
?endometriosis
-25Sperm DNA damage
Abnormalities in oocyte cytoskeleton function
Decreased antimllerian hormone
Mechanism is not clearly established
Answer: Mechanism is not clearly established. In early-stage endometriosis, an
abnormal peritoneal environment may cause sperm DNA damage and abnormalities

in oocyte skeleton function. Additionally, antimllerian hormone, a marker of ovarian

reserve, is decreased in early-stage disease, and ovarian cysts and adhesions
observed in more advanced endometriosis can result in abnormal tubal function.
Though all of these factors could contribute to endometriosis-related infertility, the
mechanism of infertility in this setting is not clearly established.
Your 29-year-old patient presents with chronic pelvic pain associated with the -87
onset of menses. She continues to describe painful defecation during menses and
severe dyspareunia. No adnexal mass is detectable on pelvic exam. You suspect
endometriosis. According to the ACOG, what is the imaging modality of choice in this
?scenario
Transvaginal ultrasonography
MRI
CT
Imaging studies are not indicated in this scenario
Answer: Transvaginal ultrasonography. According to the ACOG, transvaginal
ultrasonography is the imaging modality of choice when assessing for endometriosis.
Consider a laboring woman receiving oxytocin. Tachysystole occurs in the -88
presence of recurrent late fetal heart rate decelerations. What is the best
?management strategy in this setting
No interventions required
Decrease oxytocin dose
Decrease or stop oxytocin and initiate intrauterine resuscitation
Initiate intrauterine resuscitation
Answer: Decrease or stop oxytocin and initiate intrauterine resuscitation. In the
setting of labor induction or augmentation, if uterine tachysystole occurs in the
presence of a Category II or III fetal heart rate tracing, oxytocin should be reduced or
stopped in addition to the initiation of intrauterine resuscitative measures.
Assume that, in the setting of the previous question, a Category III fetal heart -89
rate tracing continues and intrauterine resuscitative measures are unsuccessful.
According to ACOG guidelines, over what time interval should delivery be
?accomplished
Acceptable time frame not established
Within 30 minutes
Within 45 minutes
Within 1 hour
Answer: Acceptable time frame not established. The acceptable time frame to
accomplish delivery in the setting of a Category III fetal heart rate tracing has not
been established. According to the ACOG Practice Bulletin, when a decision for
operative delivery in this setting is made, it should be accomplished as expeditiously
as feasible. Additionally, the decision-to-incision interval and mode of delivery should
be based on the timing that best incorporates maternal and fetal risks and benefits.

-26-

:Consider 4 female patients -90

Patient A: 1 previous cesarean delivery with a low-transverse incision
Patient B: 2 previous low-transverse cesarean deliveries
Patient C: 1 previous low-transverse cesarean delivery, who is otherwise an
appropriate candidate for twin vaginal delivery
Patient D: 1 previous cesarean delivery with a classical incision
Based solely on this information, which patient(s) may be considered candidates for
?a trial of labor after previous cesarean delivery (TOLAC)
Patient A only
Patients A and B
Patients A, B, and C
Patients A, B, C, and D
Answer: Patients A, B, and C. According to the ACOG Practice Bulletin, most women
with one previous cesarean delivery with a low-transverse incision are candidates for
and should be counseled about vaginal birth after cesarean delivery (VBAC) and
offered TOLAC. Other candidates for TOLAC may include women with 2 previous
low-transverse cesarean deliveries and women with 1 previous low-transverse
cesarean delivery who are otherwise appropriate candidates for twin vaginal delivery.
TOLAC is not contraindicated for women with previous cesarean delivery with
unknown uterine scar type, unless there is a high clinical suspicion of a previous
classical uterine incision.
Which metabolite has been identified as abnormal in first-trimester maternal -91
?serum of Down syndrome (DS) pregnancies
Arginine
3-hydroxybutyrate
Glutamine
Creatinine
Answer: 3-hydroxybutyrate. A recent study performed first-trimester maternal serum
metabolomics analysis in aneuploid vs DS pregnancies. This study showed that the
combination of 3-hydroxyisovalerate, 3-hydroxybutyrate, and maternal age had a
51.9% sensitivity at 1.9% false-positive rate for DS detection. Novel markers, such as
3-hydroxybutyrate, involved in brain growth and myelination, and 2-hydroxybutyrate,
involved in the defense against oxidative stress, were found to be abnormal in DS
pregnancies.
Consider a population of parous women aged 45 years with an intact uterus, -92
who had not been diagnosed with high blood pressure before pregnancy. Among
women meeting this criteria, those who breastfed for longer than what lifetime
?duration were less likely to have high blood pressure later in life
>3 months
>6 months
>9 months
>12 months
Answer: >6 months. A retrospective study, including data from nearly 75,000 women
from the Australian 45 and Up Study, showed that women who breastfed for >6
months in their lifetime, or >3 months per child, on average, had significantly lower
odds of having high blood pressure when compared with parous women who never
breastfed. Based on these data, the authors concluded that a woman's breastfeeding

-27history should be taken into account when assessing for high blood pressure in later
life.
Your 31-year-old nulliparous patient became spontaneously pregnant with -93
dichorionic twins. The twins were born at 32 weeks' gestation. According to a
retrospective cohort study of similar patients, what is the optimal time interval
between a single course of antenatal corticosteroids (ACS) and delivery for reduction
?of respiratory distress syndrome (RDS) in this scenario
<2 days
27 days
>7 days
No significant interaction between RDS incidence and timing of ACS
Answer: 27 days. A retrospective cohort study of twins born between 2434 weeks'
gestation found that a single course of ACS treatment was associated with a
decreased rate of RDS only when the time interval from ACS administration to
delivery was between 2 and 7 days. ACS-to-delivery intervals of <2 days or >7 days
were not associated with a reduction in the incidence of RDS.
At her 6-week postpartum follow-up, your 37-year-old patient inquires about the -94
likelihood of future neurologic or behavioral problems for her son, who was born at 34
weeks' 6 days gestation following in vitro fertilization (IVF)-assisted conception. You
describe results of the Prematuritys Effects on Toddlers, Infants, and Teens (PETIT)
study that evaluated neuropsychological outcomes in preschool-aged children born
late preterm after IVF. Based solely on this information and this studys outcomes,
?what may your patient's son have a higher risk of when he is 3 years old
Intellectual and behavioral deficits
Neuropsychological deficits
Intellectual, behavioral, and neuropsychological deficits
Neither intellectual, behavioral, nor neuropsychological deficit
Answer: Neither intellectual, behavioral, nor neuropsychological deficit. The PETIT
study found that birth following IVF-assisted conception did not increase the risk of
intellectual, neuropsychological, or behavioral deficit in late preterm preschoolers.
Consider your patient in the previous question: a 37-year-old female who gave -95
birth at 34 weeks' 6 days gestation. Does this history of preterm delivery confer a
?higher risk of long-term maternal cardiovascular morbidity
Yes; she delivered at <37 weeks
Maybe; only if her delivery was spontaneous
No; she delivered at >34 weeks
No; preterm delivery is not associated with cardiovascular morbidity
Answer: Yes; she delivered at <37 weeks. A large study showed that after >10 years
of follow-up, patients with a history of both preterm delivery (whether early or late,
spontaneous or induced) had higher rates of simple and complex cardiovascular
events and total cardiovascular-related hospitalizations. These and other data
suggest that preterm delivery is an independent risk factor for long-term maternal
cardiovascular morbidity.

Your 17-year-old patient underwent bariatric surgery within the last year. How -96
does the pregnancy rate for such a patient compare with that of the general
?adolescent population
About the same
1.5 times higher
-282 times higher
3 times higher
Answer: 2 times higher. The ACOG Practice Bulletin suggests contraceptive
counseling is important for adolescents after bariatric surgery because pregnancy
rates in this patient population are double the rate in the general adolescent
population (12.8% vs 6.4%).
In general, which method of contraception is NOT recommended for your -97
?adolescent patient in the previous question
Oral contraceptive
Patch
Ring
IUD
Answer: Oral contraceptive. There is an increased risk of oral contraception failure
after bariatric surgery with a significant malabsorption component. Therefore, nonoral
administration of hormonal contraception should be considered for reproductive-aged
women undergoing bariatric surgery.
In which setting should the use of combination hormonal contraceptives NOT be -98
?considered
Treatment of existing functional ovarian cysts
Regulation or reduction of menstrual bleeding
Treatment of dysmenorrhea
Treatment of acne
Answer: Treatment of existing functional ovarian cysts. The ACOG Practice Bulletin
states that combined oral contraceptives have been shown to regulate and reduce
menstrual bleeding, treat dysmenorrhea, reduce premenstrual dysphoric disorder
symptoms, and ameliorate acne. Although hormonal contraception may reduce the
findings of follicular and corpus luteal cysts on ultrasound, combined oral
contraceptives should not be used to treat existing functional ovarian cysts.
Your 30-year-old patient presents with premature rupture of membranes at 38 -99
weeks' 2 days gestation. Which maternal or fetal condition is a contraindication to
?induction of labor in this scenario
Abruptio placentae
Chorioamnionitis
Gestational hypertension
Active genital herpes infection
Answer: Active genital herpes infection. According to the ACOG Practice Bulletin,
contraindications to labor induction are the same as those for spontaneous labor and
vaginal delivery. They include, but are not limited to, vasa previa or complete
placenta previa, transverse fetal lie, umbilical cord prolapse, previous classical

cesarean delivery, active genital herpes infection, and previous myomectomy

entering the abdominal cavity.
This patient has no contraindications to labor induction, and you induce at the -100
time of presentation via administration of a 0.5-mU/min oxytocin infusion. According
to ACOG guidelines, over what time interval should the oxytocin dose be increased, if
?clinically necessary
1540 min
1030 min
2050 min
-293060 min
Answer: 1540 min. For the low-dose oxytocin regimen, ACOG recommends an
incremental increase of 12 mU/min over a dosage interval of 1540 minutes. It
should be noted that low-dose oxytocin regimens and less frequent increases in dose
are associated with decreased uterine tachysystole with associated fetal heart rate
changes.