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1. A 17-year-old G1P0 female at 39 weeks presents with Correct answer is E. This patient has a diagnosis of preeclampsia.
increased swelling in her face and hands over the last two Delivery is recommended for women with gestational hypertension or
days. Her blood pressure is 155/99. She has 2 plus pitting preeclampsia without severe features at or beyond 37 0/7 weeks of
edema of the lower extremities. A 24-hour urine collection gestation. Fluid management must be monitored closely in this person
shows 440 mg of protein. What is the next best step in the as patients with preeclampsia are at risk for developing pulmonary
management of this patient? edema. Treatment with magnesium sulfate is not recommended for
women with preeclampsia with systolic BP of less than 160 mm Hg and
A. Fluid restriction a diastolic BP less than 110 mm Hg and no maternal symptoms.
B. Magnesium sulfate Diuretics should not be administrated to this patient as it might further
C. Furosemide deplete her intravascular volume, but may be indicated in the setting
D. Hydralazine of pulmonary edema. Treatment with antihypertensive agents is not
E. Delivery indicated for patients with preeclampsia with a persistent BP of less
than 160 mm Hg systolic or 110 mm Hg diastolic.
2. An 18-year-old G1 woman at 32 weeks gestation presents This patient has a placental abruption. Common presenting signs of an
with severe abdominal pain and a small amount of abruption include abdominal pain, bleeding, uterine hypertonus and
bleeding. She has received routine prenatal care, smokes fetal distress. Risk factors include smoking, cocaine use, chronic
one pack of cigarettes per day and admits to using crack hypertension, trauma, prolonged premature rupture of membranes,
cocaine. On exam, her blood pressure is 140/80, pulse 100 and history of prior abruption. Treatment would involve an emergent
and she is afebrile. Her uterus is tense and very tender. Cesarean section with appropriate resuscitation, including intravenous
Pelvic ultrasound reveals a fundal placenta, cephalic fluids and blood products as needed. A placenta previa is an
presentation of the fetus and no other abnormalities. abnormal location of the placenta.
Cervical examination reveals blood coming through the os
and is one centimeter dilated. Fetal heart tones have a
baseline of 160s, with a category III tracing. Which of the
following is the most likely diagnosis?
A. Placenta previa
B. Premature rupture of the membranes
C. Preterm labor
D. Placental abruption
E. Chorioamnionitis
3. A 19-year-old G2P1 African American woman at 30 weeks The primary risk factor for preterm rupture of membranes is genital
gestation presents with preterm rupture of membranes six tract infection, especially associated with bacterial vaginosis. All of the
hours ago. Her prenatal course has been complicated by other listed options are risk factors. Smoking and prior preterm
two episodes of bacterial vaginosis for which she was premature rupture of membranes (which she did not have previously
treated. She takes prenatal vitamins and iron. She denies because she delivered at 41 weeks) increases the likelihood of preterm
substance abuse or alcohol use, but admits to smoking five rupture of membranes two-fold. A shortened cervical length is also a
cigarettes each day. Her prior pregnancy was delivered risk factor, but her cervical length is normal.
vaginally at 41 weeks after spontaneous rupture of
membranes. Her blood pressure is 110/70; pulse 84;
temperature 98.6F (37.0C). Pertinent sonographic findings
reveal oligohydramnios and a cervical length of 30 mm.
Which of the following is the most likely cause of preterm
premature rupture of membranes in this patient?
A. Ethnicity
B. Smoking
C. Previous premature rupture of membranes
D. Cervical length
E. Genital tract infections
4. A 20-year-old G1 woman at 40 weeks gestation Correct answer is C. The patient is in the latent phase of labor and has not
presents to labor and delivery complaining of painful yet reached the active phase (more than 4 cm). A prolonged latent phase
contractions every 3-4 minutes since midnight. Her is defined as >20 hours for nulliparas and >14 hours for multiparas, and may
examination on admission was 2 centimeters dilated, be treated with rest or augmentation of labor. Artificial rupture of
90% effaced and 0 station. Three hours later, her exam membranes is not recommended in the latent phase as it places the patient
is unchanged. The patient is still having contractions at increased risk of infection. Cervical dilation or laminaria placement are
every 3-4 minutes. She is discouraged about her lack not indicated.
of progress. Which of the following is the most
appropriate next step in the management of this
patient?
A. Laminaria placement
B. Artificial rupture of membranes
C. Counseling about latent phase of labor and rest
D. Manual cervical dilation
E. Cesarean section for arrest of labor
5. A 23-year-old G1P1 woman delivered her first baby two Correct answer is D. Breast engorgement is an exaggerated response to
days ago after an uncomplicated labor and vaginal the lymphatic and venous congestion associated with lactation. Milk "let-
delivery. She wants to breastfeed and has been down" generally occurs on postpartum day two or three. If the baby is not
working with the lactation team. Prior to discharge, her feeding well, the breast can become engorged, which can cause a low-
temperature was 100.4 F (38 C) and other vitals were grade fever. Lactating women are encouraged to feed their baby
normal. She denies urinary frequency or dysuria and frequently, and use a breast pump to prevent painful engorgement and
her lochia is mild without odor. On examination, her mastitis. Postpartum fever differential includes endometritis, cystitis and
lungs are clear, cardiac exam normal, and abdomen mastitis. These are easy distinguished, based on clinical findings. Vaginitis is
and uterine fundus are nontender. Her breasts are firm not accompanied by fever. Septic pelvic thrombophlebitis is a rare
and tender throughout, without erythema, and nipples condition and characterized by high fever not responsive to antibiotics and
are intact. Which of the following is the most likely is a diagnosis of exclusion.
cause of her fever?
A. Endomyometritis
B. Septic pelvic thrombophlebitis
C. Mastitis
D. Breast engorgement
E. Vaginitis
6. A 24-year-old G1P0 at 32 weeks gestation presents Correct! 30 cc of fetal blood is neutralized by the 300 micrograms dose of
with vaginal bleeding most likely caused by placental RhoGAM. This is equivalent to 15 cc of fetal red blood cells. At 28-weeks
abruption. She receives a standard dose of 300 gestation, 300 micrograms of Rh-immune globulin is routinely administered
micrograms of RhoGAM. What amount of fetal blood is after testing for sensitization with an indirect Coombs' test. Administration
neutralized by this dose? is given following amniocentesis at any gestational age.
A. 10 cc
B. 20 cc
C. 30 cc
D. 40 cc
E. 50 cc
7. A 24-year-old G2P1 woman has a fetus that is affected Correct answer is C. Values in Zone 3 of the Liley curve indicate the
by Rh disease. At 30 weeks gestation, the delta OD450 presence of severe hemolytic disease, with hydrops and fetal death likely
(optical density deviation at 450 nm) results plot on the within 7-10 days, thus demanding immediate delivery or fetal transfusion. At
Liley curve in Zone 3 indicating severe hemolytic 30 weeks gestation, the fetus would benefit from more time in utero. An
disease. Which of the following is the most appropriate attempt should be made to correct the underlying anemia. Intravascular
next step in the management of this patient? transfusion into the umbilical vein is the preferred method. Intraperitoneal
A. Immediate Cesarean delivery transfusion is used when intravascular transfusion is technically impossible.
B. Induction of labor If fetal hydrops is present, the reversal of the fetal anemia occurs much
C. Intrauterine intravascular fetal transfusion more slowly via intraperitoneal transfusion. Percutaneous umbilical blood
D. Umbilical blood sampling sampling should not be used as a first-line method to evaluate fetal status.
E. Maternal plasmapheresis Maternal plasmapheresis is used in severe disease when intrauterine
transfusions are not possible.
8. A 24-year-old G2P1 woman is diagnosed with Rh hemolytic Correct! In the presence of a severely erythroblastotic fetus, the
disease at 24 weeks gestation. Measurement of which of the amniotic fluid is stained yellow. The yellow pigment is bilirubin,
following in the amniotic fluid is best indicative of the severity which can be quantified most accurately by spectrophotometric
of the disease? measurements of the optical density between 420 and 460nm, the
A. Hemoglobin wavelength absorbed by bilirubin. The deviation from linearity of
B. Iron the optical density reading at 450nm is due to the presence of
C. Anti-D antibody titer heme pigment, an indicator of severe hemolysis.
D. Glucose
E. Bilirubin
9. A 24-year-old Rh-negative G1P1 woman just delivered a Correct answer is A.
healthy term infant who is Rh-positive. You recommend
RhoGAM administration but she declines because she does The risk of isoimmunization is 2% antepartum, 7% after full term
not desire any blood products. What is her approximate risk delivery, and 7% with subsequent pregnancy.
of isoimmunization if she does not receive the RhoGAM?
A. 0-7 weeks
B. 8-15 weeks
C. 16-25 weeks
D. 26-30 weeks
E. 31-35 weeks
23. A 35-year-old G3P3 woman comes to the Correct answer is B. Tubal ligation has not been shown to reduce the risk of breast,
office to discuss tubal ligation as she desires cervical, or endometrial cancers, nor is there a decrease in menstrual blood flow in
permanent sterilization. The non- women who have undergone a tubal ligation. There is a slight reduction in the risk
contraceptive health benefits of female of ovarian cancer, but the mechanism is not yet fully understood.
sterilization reduce the risk of which of the
following?
A. Breast cancer
B. Ovarian cancer
C. Endometrial cancer
D. Cervical cancer
E. Menorrhagia
24. A 36-year-old G1P0 Asian woman Correct answer is C. Assisted reproduction has led to an increase number of multiple
presents to the office accompanied by gestations. The rates of multiple births after IVF (in-vitro fertilization) vary according to
her 32-year-old husband. She is maternal age and the number of embryos transferred. Transfer of multiple embryos is more
thrilled that she is now pregnant with likely to result in multiple gestations in younger women than in older women. The frequency
twins after undergoing in vitro of multiple gestations increases with the use of ovulation inducing drugs. The risk is in the 5-
fertilization. She has a history of 6% range, but varies depending on the drug and dosage regimen used. Dizygous twinning
polycystic ovarian syndrome and results from the ovulation of multiple follicles and the rate of multiple gestation increases
thought she would not be able to have with advancing maternal age. Elevated follicle-stimulating hormone correlates with
a baby. Her husband has a twin dizygous multiple births. A higher number of prior pregnancies and previous history of
brother. Which of the following is the multiple births increases the chance of having a multiple gestation. These do not apply here
most likely cause of twins in this because the patient's obstetrical history does not support this. Dizygous twinning appears
patient? to have a genetic component and rates of dizygous twins vary according to ethnicity, but
A. Advanced maternal age are not related to paternal family history.
B. Ethnicity
C. Assisted reproductive technology
D. Nulliparity
E. Paternal family history
25. A 37-year-old G4P3 woman presents Correct answer is D. Prostaglandin F2-alpha should be administered intramuscularly. It
in labor at term. Her medical history could also be injected directly into the uterine muscle. Prostaglandin F2-alpha should not
and prenatal course are be administered IV, as it can lead to severe bronchoconstriction. Oxytocin is administered
uncomplicated. She delivers a 3500 as a short time, rapid infusion of a dilute solution (20-80 units in a liter) and not as an IV
gram infant spontaneously after bolus/push. Misoprostol (800 to 1000 mcg) can be administered orally or rectally and is not
oxytocin augmentation of labor. administered IV or IM.
Immediately postpartum, there is
excessive bleeding greater than 2000
cc. She has an IV in place. There are
no lacerations and the uterus is found
to be boggy. Which of the following is
the most appropriate next step in the
non-operative management of this
patient?
A. Intravenous misoprostol
B. Intramuscular misoprostol
C. Intravenous prostaglandin F2-alpha
D. Intramuscular prostaglandin F2-
alpha
E. Intravenous oxytocin push
26. A 38-year-old G2P0 woman at 28 weeks gestation has been Treatment with betamethasone from 24 to 34 weeks gestation
diagnosed with preterm labor and is currently stable on nifedipine. has been shown to increase pulmonary maturity and reduce
Her cervical exam has remained unchanged at 2 cm dilated, 75% the incidence and severity of RDS (respiratory distress
effaced and -2 station. Her vital signs are stable and fetal heart syndrome) in the newborn. It is also associated with
tracing is category I. You recommend treatment with decreased intracerebral hemorrhage and necrotizing
betamethasone (a steroid). Which of the following is associated enterocolitis in the newborn. It has not been associated with
with betamethasone therapy in the newborn? increased infection or enhanced growth.
A. Enhancement of fetal growth
B. Increased risk of infection
C. Increased incidence of necrotizing enterocolitis
D. Increased incidence of intracerebral hemorrhage
E. Decreased incidence of intracerebral hemorrhage
27. A 40-year-old G1P0 woman at 22 weeks gestation presents to the B. The most likely cause of painless cervical dilation which
office with a complaint of pelvic pressure. She reports that she had leads to pelvic pressure, bulging membranes and fetal loss is
intercourse the night prior to presentation and noted some mucous cervical incompetence or insufficiency. This patient has a
mixed with blood this morning. Her history is significant for type 1 history of cone biopsy which can lead to cervical
diabetes and she is on an insulin pump. Her surgical history is incompetence. Preterm labor by definition does not occur
significant for a history of cone biopsy for treatment of abnormal until 24 weeks gestation. Although uncontrolled diabetes can
Pap smear three years ago. On examination, her BMI is 26. She is lead to fetal malformations and early miscarriage, it is not
noted to have a 2 cm dilated cervix with bulging membranes that typically a cause of fetal loss in the second trimester.
rupture upon placing the speculum. Fetal parts are noted in the Advanced maternal age is associated with an increased risk of
vagina. What is the most likely cause of this finding? stillbirth, preeclampsia, gestational diabetes and intrauterine
growth restriction.
A. Uncontrolled diabetes
B. Cervical incompetence/insufficiency
C. Preterm labor
D. Advanced maternal age
E. Infection
28. A 48-year-old G2P2 woman comes to your office because she has Although there has been a decline in the average age of
skipped her menstrual period for the past three months. She menarche with the improvement in health and living
denies any menopausal symptoms. Review of symptoms and conditions, the average age of menopause has remained
physical exam are unremarkable. What is the most likely diagnosis stable. The Massachusetts Women's Health Study reports that
in this patient? the average age of menopause is 51.3. This patient is most
likely perimenopausal and will probably have more menstrual
A. Hypothyroidism periods in the future. Although it is important to consider
B. Early pregnancy pregnancy and hypothyroidism, this patient's presentation is
C. Perimenopause most consistent with perimenopause. Premature ovarian
D. Premature ovarian failure failure occurs before age 35.
E. Autoimmune disorder
29. A 49-year-old G1P1 woman comes to your office for menopause Recent data have confirmed the overall positive effects of
counseling. She has been experiencing severe sleep disturbances hormone therapy on serum lipid profiles. The most important
and night sweats for the past four months. She would like to begin lipid effects of postmenopausal hormone treatment are the
hormone therapy, but is concerned because she has elevated reduction in LDL cholesterol and the increase in HDL
cholesterol levels for which she takes medication. You explain to cholesterol. Estrogen increases triglycerides and increases
her that hormone therapy has the following effect on a LDL catabolism, as well as lipoprotein receptor numbers and
lipid/cholesterol profile: activity, therefore causing decreased LDL levels. Hormones
inhibit hepatic lipase activity, which prevents conversion of
A. Both HDL and LDL levels increase HDL2 to HDL3, thus increasing HDL levels. Hormone therapy
B. Both HDL and LDL levels decrease is not currently recommended for the primary prevention of
C. HDL and LDL levels are unaffected heart disease.
D. HDL levels increase and LDL levels are unaffected
E. HDL levels increase and LDL levels decrease
30. A 49-year-old G2P2 woman status post hysterectomy at age 45 for Except for estrogen receptor modulator therapy, all of the
fibroids presents to your office complaining of severe vasomotor above treatment options will improve hot flash symptoms.
symptoms for three months. Hot flashes are affecting her quality of Treatment with estrogen is most effective, and the current
life and she would like to discuss options for treatment. What recommendation is for the lowest dose for the shortest
treatment option for hot flashes associated with menopause do you duration of time. Hot flashes will resolve completely in 90%
recommend as the most effective? of patients receiving this therapy. Raloxifene, a selective
estrogen receptor modulator, may actually cause hot
A. Lifestyle modifications such as dressing in layers flashes to worsen in a patient who has not stopped having
B. Estrogen these symptoms completely. SSRI antidepressants, some
C. Selective estrogen receptor modulator (SERMs) anti-seizure medications and alternative treatments, such as
D. Selective serotonin reuptake inhibitors (SSRIs) soy products and herbs, have not been shown to be as
E. Treatment with phytoestrogen (soy) effective as estrogen.
31. A 51-year-old G1P1 woman presents for annual examination. She Expectant management is reasonable in this patient, as she
notes vaginal dryness, some hot flashes, and fatigue. She reports that notes minimal menopausal symptoms. Her vaginal dryness
her last menstrual period was 14 months ago. She and her husband is not interfering with her ability to enjoy intercourse, and
use lubrication for intercourse, and she denies any significant pain. she has only occasional hot flashes. An FSH level is not
Her past medical history is significant for hypertension, which she indicated as by definition she is menopausal given
controls with diet and regular exercise. She is concerned that she amenorrhea for greater than 12 months. Estrogen and LH
should begin hormone replacement, because her mother started HRT levels are not indicated in the diagnosis of menopause.
around the same age. Which of the following is the most appropriate While HRT is appropriate for patients with significant
next step in her management? menopausal symptoms, and should be used at the lowest
effective dose for the shortest amount of time, this patient
A. Expectant management at this time is not experiencing significant symptoms and
B. FSH level therefore HRT should not be initiated at this time.
C. LH level
D. Estrogen level
E. Initiate combination HRT
32. A 53-year-old G2P2 woman comes to your office complaining of six The principal symptom of endometrial cancer is abnormal
months of worsening hot flashes, vaginal dryness, night sweats, and vaginal bleeding. Although the patient's worsening
sleep disturbances. Her last normal menstrual period was six months symptoms make treatment an important consideration, the
ago and she has been experiencing intermittent small amounts of specific organic cause(s) of abnormal bleeding must be
vaginal bleeding. Her medical history is significant for hypertension, ruled out prior to initiating therapy. A tissue diagnosis
which is well-controlled by a calcium-channel blocker, type 2 consistent with normal endometrium or a pelvic ultrasound
diabetes, for which she takes metformin, and hyperthyroidism, for with an endometrial stripe of <4 mm ought to be
which she takes propylthiouracil. The patient is 5 feet 7 inches tall documented. In addition, risks and benefits of hormone
and weighs 140 pounds. Blood pressure is 120/70. Physical replacement therapy must be discussed with this patient at
examination is unremarkable. Which of the following medical length prior to beginning treatment.
conditions in this patient is a contraindication to treatment of
menopausal symptoms with hormone therapy?
A. Vaginal bleeding
B. Hypertension
C. Diabetes
D. Osteoporosis
E. Hyperthyroidism
33. A 54-year-old G2P2 woman presents to your office for The American College of Obstetricians and Gynecologists (ACOG)
a health maintenance examination. Her last menstrual recommendations on hormone replacement therapy considers hormone
period was eight months ago. She complains of severe replacement therapy (HRT) the most effective treatment for severe
vasomotor symptoms, vaginal dryness, and menopausal symptoms that include hot flashes, night sweats and vaginal
dyspareunia, and desires treatment for her symptoms. dryness. The physician should counsel the woman about the risks and
She has otherwise been in good health and has no benefits before initiating treatment. ACOG recommends "the smallest
significant past medical or surgical history. Her family effective dose for the shortest possible time and annual reviews of the
history is significant for a mother who has severe decision to take hormones." HRT should not be used to prevent
osteoporosis at the age of 75, a grandmother who died cardiovascular disease due to the slight increase in risk of breast cancer,
of breast cancer at the age of 79, and a father who died myocardial infarction, cerebrovascular accident, and thromoboembolic
at age 77 from a myocardial infarction. She denies events. A woman with an intact uterus should not use estrogen-only
smoking, alcohol or drug use. On physical exam her BP therapy because of the increased risk of endometrial cancer. In addition
is 130/78, pulse is 84, and BMI is 26. The remainder of to the same risks as FDA approved treatments, bioidentical hormones
her exam is within normal limits except for severe such as testosterone and progesterone cream may have additional
vaginal atrophy noted on the pelvic examination. The associated risks. While her family history is significant for one second
best recommendation for this patient would include degree relative with breast cancer, this is not an absolute
which of the following? contraindication for short-term HRT.
A. None
B. 400 mg
C. 800 mg
D. 1200 mg
E. 1600 mg
37. A 58-year-old G3P3 woman who has been menopausal since The World Health Organization (WHO) defines osteopenia (low
age 50 comes to you for a health maintenance examination. bone mass) as -1 to -2.5. The American College of Obstetricians and
She is in good health, eats a balanced diet, exercises Gynecologists (ACOG) Committee Opinion recommends that
regularly, and has an unremarkable physical exam. Her bone physicians interpret T scores between 1.0 and 2.5 in combination
mineral density as determined by central dual energy X-ray with the patient's risk factors for fracture. The authors state:
absorptiometry is -1.7. She wants to discuss treatment for her "Clinicians must be careful because the diagnosis of osteopenia
osteopenia. What is the next step in the management of this often is interpreted as indicating a pathologic skeletal condition or
patient? significant bone loss, neither of which is necessarily true. Until better
models of absolute fracture risk exist, postmenopausal women in
A. Evaluate her risk factors for fracture their 50s with T scores in the osteopenia range and without risk
B. Determine her frequency of exercise factors may well benefit from counseling on calcium and vitamin D
C. Assess her exogenous dietary intake of estrogen intake and risk factor reduction to delay initiation of pharmacologic
D. Assess her exogenous dietary intake of progesterone intervention." Some of the risk factors for fracture include prior
E. Repeat DEXA scan in one year fracture, family history of osteoporosis, race, dementia, history of
falls, poor nutrition, smoking, low body mass index, estrogen
deficiency, alcoholism, and insufficient physical activity.
38. Factors Prematurity, multiple gestation, genetic disorders, polyhydramnios, hydrocephaly, anencephaly, placenta previa,
associated w/ uterine anomalies and uterine fibroids are all associated with breech presentation.
breech
presentation
39. How calcium 1,200 mg
should be given
to a
postmenopausal
woman?
40. Infertility facts After one month, 20% of couples will conceive; after three months, 50%; after six months, 75%; and after 12
months, 90% will conceive. Primary infertility is defined as the inability to conceive for one year without
contraception. The patient is young and healthy with no obvious reasons for infertility, so at this point reassurance
and observation is the proper management.
41. Obstetric The FVL mutation is associated with obstetric complications including stillbirth, preeclampsia, placental abruption
complications: and IUGR. Fetuses with Trisomy 18 are likely to have congenital anomalies that are detectable on prenatal
FVL mutation, ultrasound. Over 90% of cases of trisomy 21 and 18 may be detected with the quad screen. A congenital
Trisomy 18,21, parvovirus infection associated with a fetal demise would likely cause hydrops in the fetus which would be
diabetes, and identified on ultrasound. Although poorly controlled diabetes mellitus are associated with fetal demise, they are
parvo. not the most likely etiologies in this patient whose presentation is classic for the FVL mutation.
42. The operative Correct answer is D. Correcting coagulation deficiencies requires replacing all necessary blood components.
team decides to Fresh frozen plasma contains fibrinogen, as well as clotting factors V and VIII. Cryoprecipitate contains fibrinogen,
give her fresh factor VIII and von Willebrand's factor. Neither of these preparations contains red blood cells or platelets, which
frozen plasma must be given separately.
(FFP) to replace
which of the
following
components?
A. Platelets
B. Von
Willebrand's
factor
C. Red blood
cells
D. Fibrinogen
E. Factor X
43. Outline some Other risk factors for preeclampsia include a previous history of the disease, chronic hypertension, multifetal
risk factors for pregnancy and molar pregnancy. In addition, patients at extremes of maternal age or with diabetes, chronic renal
pre-eclampsia. disease, antiphospholipid antibody syndrome, vascular or connective tissue disease or triploidy are at increased
risk for developing preeclampsia
44. read. Uncontrolled glucose is associated with adverse fetal outcome. A patient with type 1 diabetes is at risk for many
pregnancy complications, including fetal death and fetal macrosomia, although fetal growth restriction may also
occur. Diabetics also have increased risk for polyhydramnios, congenital malformations (cardiovascular, neural
tube defects, and caudal regression syndrome), preterm birth, and hypertensive complications. The anemia most
often seen in pregnancy is mild and would not be the most likely cause. It is unlikely that she has an abruption
causing the anemia, but this should be considered. Hypothyroidism is usually associated with menstrual
irregularities and infertility, and is a less likely cause. Rh sensitization is unlikely since this is her first pregnancy and
she did not have any bleeding or procedures during the pregnancy.
45. Read card. Fetal hydrops is easily diagnosed on ultrasound. It develops in the presence of decreased hepatic protein
production. It is defined as a collection of fluid in two or more body cavities, such as ascites, pericardial and/or
pleural fluid and scalp edema. On occasion, when extramedullary hematopoiesis is extensive, there will be
evidence of hepatosplenomegaly. Placentomegaly (placental edema) and polyhydramnios are also seen on
ultrasound. Meconium, fetal bladder obstruction, oligohydramnios and placenta previa do not fit the clinical
scenario.
46. A therapeutic 4-7 mEq/L.
magnesium level is
between _________
47. Uncontrolled diabetes Uncontrolled diabetes during organogenesis is associated with a high rate of birth defects. The most
during pregnancy common sites affected are the spine and the heart of the fetus, although all birth defects are increased.
Fetuses in utero exposed to high levels of glucose transplacentally have increased growth and polyuria
resulting in an increase in the amniotic fluid. While some viral infections are also associated with
placentomegaly and polyhydramnios, the fetus will have normal or decreased growth depending on the
timing of the infection. Severe hypertension and active APAS is often associated with oligohydramnios and
intrauterine growth restriction. The risk of miscarriage is increased if hypothyroidism goes untreated.
48. What happens at a Loss of deep tendon reflexes
magnesium level of 7-
10 mEq/L
49. What happens at a respiratory depression
magnesium level of 11
mEq/L
50. What happens at a cardiac arrest
magnesium level of 15
mEq/L. What is a side Pulmonary edema can occur with magnesium therapy, but is not related to toxicity from the drug.
effect of magnesium
therapy associated w/
the lungs? (hint: not
related to toxicity from
the drug)
51. What is the most The routine dose of RhoGAM neutralizes 30 cc of fetal blood. The Kleihauer-Betke test is an accurate and
appropriate method to sensitive acid elution test. It has great value in determining the incidence and size of fetal transplacental
determine the correct hemorrhage. In this test, using acid elution, the mother's red blood cells become very pale, while fetal
RhoGAM dose to give cells, which contain a different form of hemoglobin, remain stained. Simple comparative counts allow an
to the patient? estimate of whether a significant fetal maternal transfusion has occurred.
A. Determine delta OD
450 (optical density)
B. Measure fetal
hemoglobin levels
C. Perform a Kleihauer-
Betke test
D. Measure maternal
hemoglobin levels
E. Administer routine
dose of RhoGAM at
time of incident
Unit 2: Obstetrics A - Normal Obstetrics
Study online at quizlet.com/_2iibny
1. A 16-year-old G1P0 woman at 39 weeks gestation presents to labor and B. If the fetal heart rate cannot be confirmed using
delivery reporting a gush of blood-tinged fluid approximately five hours external methods, then the most reliable way to
ago and the onset of uterine contractions shortly thereafter. She reports document fetal well-being is to apply a fetal scalp
contractions have become stronger and closer together over the past electrode. Putting in an epidural without confirming fetal
hour. The fetal heart rate is 140 to 150 with accelerations and no status might be dangerous. Although ultrasound will
decelerations. Uterine contractions are recorded every 2-3 minutes. A provide information regarding the fetal heart rate, it is
pelvic exam reveals that the cervix is 4 cm dilated and 100 percent not practical to use this to monitor the fetus
effaced. Fetal station is 0. After walking around for 30 minutes the patient continuously while the epidural is placed. An intrauterine
is put back in bed after complaining of further discomfort. She requests pressure catheter will provide information about the
an epidural. However, obtaining the fetal heart rate externally has strength and frequency of the patient's contractions, but
become difficult because the patient cannot lie still. What is the most will not provide information regarding the fetal status.
appropriate next step in the management of this patient? Closer fetal monitoring via a fetal scalp electrode
should be performed.
A. Place the epidural
B. Apply a fetal scalp electrode
C. Perform a fetal ultrasound to assess the fetal heart rate
D. Place an intrauterine pressure catheter (IUPC)
E. Recommend a Cesarean delivery
2. A 17-year-old G1P0 woman at 32 weeks gestation complains of right flank C. Some degree of dilation in the ureters and renal
pain that is "colicky" in nature and has been present for two weeks. She pelvis occurs in the majority of pregnant women. The
denies fever, dysuria and hematuria. Physical examination is notable for dilation is unequal (R > L) due to cushioning provided by
moderate right costovertebral angle tenderness. White blood cell count the sigmoid colon to the left ureter and from greater
is 8,800/mL and urine analysis is negative. A renal ultrasound reveals no compression of the right ureter due to dextrorotation of
signs of urinary calculi, but there is moderate (15 mm) right the uterus. The right ovarian vein complex, which is
hydronephrosis. Which of the following is the most likely cause of these remarkably dilated during pregnancy, lies obliquely over
findings? the right ureter and may contribute significantly to right
ureteral dilatation. High levels of progesterone likely
A. Smooth muscle relaxation due to declining levels of progesterone have some effect but estrogen has no effect on the
B. Smooth muscle relaxation due to increasing levels of estrogen smooth muscle of the ureter
C. Compression by the uterus and right ovarian vein
D. Elevation of the bladder in the second trimester
E. Iliac artery compression of the ureter
3. A 17-year-old G1P1 female delivered a term infant two days ago. She is B. Hormonal interventions for preventing lactation
not interested in breastfeeding and she asks for something to suppress appear to predispose to thromboembolic events, as
lactation. Which of the following is the safest method of lactation well as a significant risk of rebound engorgement.
suppression in this patient? Bromocriptine, in particular, is associated with
hypertension, stroke and seizures. The safest method to
A. Bromocriptine suppress lactation is breast binding, ice packs and
B. Breast binding, ice packs and analgesics analgesics. The patient should avoid breast stimulation
C. Medroxyprogesterone acetate or other means of milk expression, so that the natural
D. Oral contraceptives inhibition of prolactin secretion will result in breast
E. Manual milk expression involution.
4. An 18-year-old G1P0 Asian woman is seen in the clinic for a routine prenatal visit B. There is normally a 36% increase in maternal
at 28 weeks gestation. Her prenatal course has been unremarkable but she has blood volume; the maximum is reached around
been reporting increased fatigue. She has not been taking prenatal vitamins. Her 34 weeks. The plasma volume increases 47% and
pre-pregnancy weight was 120 pounds. Initial hemoglobin at the first visit at the RBC mass increases only 17%. This relative
eight weeks gestation was 12.3 g/dL. Current weight is 138 pounds. After dilutional effect lowers the hemoglobin, but
performing a screening complete blood count (CBC), the results are notable for causes no change in the MCV. Folate deficiency
a white blood cell count 9,700/mL; hemoglobin 10.6 g/dL; mean corpuscular results in a macrocytic anemia. Iron deficiency
volume 88.2 fL (80.8 - 96.4); and platelet count 215,000/mcL. The patient denies and thalassemias are associated with microcytic
vaginal or rectal bleeding. Which of the following is the best explanation for this anemia.
patient's anemia?
A. Folate deficiency
B. Relative hemodilution of pregnancy
C. Iron deficiency
D. Beta thalassemia trait
E. Alpha thalassemia trait
5. An 18-year-old G1P0 woman at 12 weeks gestation reports nausea, vomiting, D. This patient's presentation is classic for a
scant vaginal bleeding and a "racing heart." These symptoms have been present molar pregnancy. Beta-hCG levels in normal
on and off for the past four weeks. The patient has no significant past medical, pregnancy do not reach one million. A chest x-
surgical or family history. Vital signs are: temperature 98.6F (37C); heart rate ray would be the most appropriate step, as the
120 beats/minute; blood pressure 128/78. On physical examination: uterine lungs are the most common site of metastatic
fundus is 4 cm below the umbilicus; no fetal heart tones obtained by fetal disease in patients with gestational trophoblastic
Doppler device; cervix is 1 cm dilated with pinkish/purple "fleshy" tissue disease. Though a repeat quantitative Beta-hCG
protruding through the os. Labs show: hemoglobin 8.2 gm/dL, quantitative Beta- will be required on a weekly basis, an immediate
hCG 1.0 Million IU/mL; thyroid-stimulating hormone (TSH) undetectable; free T4 post-operative value will be of little clinical
3.2 (normal 0.7 - 2.5). An ultrasound reveals heterogeneous cystic tissue in the utility. A PET scan is not indicated and the
uterus (snowstorm pattern). Which of the following is the most appropriate next patient already had a CBC done.
step in the management of this patient?
A. Hyperprolactinemia
B. Hyperthyroidism
C. Sheehan Syndrome
D. Asherman Syndrome
E. Major depressive disorder
13. A 22-year-old G1P0 woman at 38 weeks A. Newer forms of vacuum extractors cause less maternal discomfort as they are
gestation has been pushing for four hours. applied to the vertex of the fetal head and do not take up additional space in the
You recommend an operative vaginal maternal pelvis. If properly applied, this leads to a decreased rate of maternal
delivery. In obtaining informed consent, lacerations. Fetal and neonatal complications related to vacuum use include lacerations
which of the following is less likely to at the edges of the vacuum cup, particularly if torsion is applied. Torsion may also lead
occur during a vacuum delivery vs. to separation of the fetal scalp from the underlying structures can cause a
forceps assisted delivery? cephalohematoma and places the fetus at risk of jaundice. Transient neonatal lateral
rectus paralysis has been found to occur more frequently in vacuum-assisted deliveries,
but, because the paralysis resolves spontaneously, it is unlikely to be of clinical
A. Maternal lacerations importance.
B. Fetal cephalohematoma
C. Neonatal lateral rectus paralysis
D. Neonatal hyperbilirubinemia
E. Neonatal retinal hemorrhage
14. A 22-year-old G1P0 woman at 38 weeks
gestation presents in labor. Her prenatal
course and past history are
uncomplicated. She is having regular
contractions and, on examination, the
cervix is 5 cm, 100% effaced and fetal head
at +1 station. The fetal heart rate tracing is
shown below. What is the most likely
interpretation? Trough of fetal heart rate
prior to peak of CTX C. Early decelerations are thought to represent the fetal response to head compression
during the contraction and the fetal heart rate inversely mirrors the changes noted
during the contraction. Variable contractions are thought to be due to cord
compression and can occur at any time in relation to a contraction. Generally, they
A. Normal reassuring have an abrupt onset and return of the fetal heart rate deceleration to the baseline
B. Bradycardia heart rate. Late decelerations are thought to represent uteroplacental insufficiency. The
C. Early deceleration deceleration of the fetal heart rate occurs at or after the peak of the uterine
D. Variable decelerations contraction and returns to baseline after complication of the contraction. Bradycardia is
E. Late decelerations defined as fetal heart rate less than 110 beats per minute.
15. A 22-year-old G1P0 woman currently at D. The tissue is consistent with omental tissue and may include segments of bowel. The
eight weeks gestation is noted to have a suction should be turned off and the tissue gently removed from the curette.
missed abortion on ultrasound, along with Laparoscopy will allow closer examination and should bowel appear to be involved,
a retroverted uterus. She elects to the surgeon should consider laparotomy for closer evaluation of the bowel for
undergo suction dilation and curettage. damage. The other options would place the patient at increased risk of complications
During the procedure, "fatty appearing and delay diagnosis.
tissue" is noted to be coming through the
curette. What is the next best step in the
management of this patient?
A. Group A streptrococcocus
B. Group B streptrococcocus
C. Staphylococcus aureus
D. Staphylococcus epidermidis
E. Candida
18. A 23-year-old G1P0 at 39 weeks D. Infants born to diabetic mothers are at increased risk for developing hypoglycemia,
gestation presents in spontaneous labor. polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress.
Pregnancy was complicated by Thrombocytopenia is not a risk.
gestational diabetes. She delivers a 4200
gram infant with ruddy color and
jitteriness. The infant is at immediate risk
for which of the following conditions?
A. Hyperglycemia
B. Anemia
C. Thrombocytopenia
D. Polycythemia
E. Hypercalcemia
19. A 23-year-old G1P0 woman at 38 weeks gestation, C. Braxton Hicks contractions are characterized as short in duration, less
with an uncomplicated pregnancy, presents to intense than true labor, and the discomfort as being in the lower abdomen and
labor and delivery with the complaint of lower groin areas. True labor is defined by strong, regular uterine contractions that
abdominal pain and mild nausea for one day. Fetal result in progressive cervical dilation and effacement. This patient's history
kick counts are appropriate. Her review of does not suggest she is in the first stage of labor. Patients with appendicitis
symptoms is otherwise negative. Vital signs are: usually present with fever, decreased appetite, nausea and vomiting.
temperature 98.6F (37.0C); blood pressure 100/60; Gestational diabetes is diagnosed based on glucose challenge tests. The first
pulse 79; respiratory rate 14; fetal heart rate 140s, test with a 50 gram load is typically performed at 24-28 weeks gestation. It is
reactive, with no decelerations; tocometer shows not abnormal for patients to have glucosuria. This finding is not diagnostic for
irregular contractions every 2-8 minutes; fundal gestational diabetes. Patients with dehydration frequently present with
height 36 cm; cervix is firm, long, closed and maternal tachycardia and have ketonuria.
posterior. A urine dipstick is notable for 1+ glucose
with negative ketones. Which of the following is the
most likely diagnosis in this patient?
A. Appendicitis
B. Gestational diabetes
C. Braxton-Hicks contractions
D. First stage of labor
E. Dehydration
20. A 23-year-old G1P1 woman delivered a healthy D. Human milk is recognized by the American Academy of Pediatrics as an
infant two days ago. She has had difficulty optimal feeding for all infants. The American Academy of Pediatrics
breastfeeding despite multiple attempts. Her recommends exclusive breastfeeding for the first six months after birth.
nipples are sore and cracked and she is thinking Physicians can influence a patient's feeding choice, and prenatal education is
about exclusively bottlefeeding. The patient's important in the initiation and maintenance of breastfeeding. Nationally
pregnancy was complicated by gestational representative surveys have noted that women were more likely to initiate
diabetes and the patient has chronic hypertension breastfeeding if their physicians or nurses encouraged it. Benefits to the
and a history of an abnormal Pap. She had a cone mother include increased uterine contraction due to oxytocin release during
biopsy two years ago and had a normal Pap with milk let down and decreased blood loss. Breastfeeding is associated with a
the current pregnancy. The patient's mother has a decreased incidence of ovarian cancer. Some studies have reported a
history of endometrial and colon cancer and her decreased incidence of breast cancer. Breastfeeding has not been shown to
maternal grandmother and grandfather both had decrease the risk for developing coronary artery disease, cervical dysplasia
fatal heart attacks in their early sixties. and cervical cancer or colon cancer in the mother. Breast milk is a major
Breastfeeding decreases the risk of which of the source of Immunoglobulin A which is associated with a decrease of newborn's
following for this patient? gastrointestinal infections.
A. Type 2 diabetes
B. Coronary artery disease
C. Cervical cancer
D. Ovarian cancer
E. Colon cancer
21. A 23-year-old G1P1 woman develops a fever on the C.
third day after an uncomplicated Cesarean
delivery that was performed secondary to arrest of The most common cause of postpartum fever is endometritis. The differential
descent. The only significant finding on physical diagnosis includes urinary tract infection, lower genital tract infection, wound
exam is moderate breast engorgement and mild infections, pulmonary infections, thrombophlebitis, and mastitis. Endometritis
uterine fundal tenderness. What is the most likely appearing in a postpartum period is most closely related to the mode of
diagnosis in this patient? delivery and occurs after vaginal delivery in approximately 2 percent of
patients and after Cesarean delivery in about 10 to 15 percent. Factors related
A. Urinary tract infection to increased rates of infection with a vaginal birth include prolonged labor,
B. Mastitis prolonged rupture of membranes, multiple vaginal examinations, internal fetal
C. Endometritis monitoring, removal of the placenta manually and low socioeconomic status.
D. Wound cellulitis Uterine fundal tenderness is commonly observed in patients with endometritis.
E. Septic pelvic thrombophlebitis
22. A 23-year-old G3P2 woman wants to exclusively breastfeed her baby. D. Hospital policies that promote breastfeeding include
She is deciding at which hospital she will deliver. Hospital policies that getting the baby on the breast within a half hour of
promote breastfeeding include which of the following? delivery and rooming-in for the baby to ensure frequent
breastfeeding on demand (i.e. unlimited access).
A. Uninterrupted sleep for the mother on her first night in the hospital
B. Use of a breast pump to help increase the milk supply
C. Use of pacifiers to prevent sore nipples
D. Unlimited access of mother to baby
E. Use of metoclopramide to increase the milk supply
23. A 24-year-old G0 woman presents to you for preconception D. Valproic acid is associated with an increased risk for
counseling. Her medical history is notable for type 1 diabetes mellitus, neural tube defects, hydrocephalus and craniofacial
hypertension, epilepsy, and hypothyroidism. Her medications include malformations. Insulin and methyldopa are not associated
insulin, methyldopa, valproic acid and levothyroxine. Based on her with fetal defects. Omphalocele and duodenal atresia are
medication exposure, her infant is at greatest risk of which of the not increased in type 1 diabetic patients.
following anatomical defects?
A. Duodenal atresia
B. Skeletal anomalies
C. Renal tubular dysgenesis
D. Neural tube defects
E. Omphalocele
24. A 24-year-old G1P0 woman at 28 weeks gestation reports difficulty B. This patient has pulmonary edema. Plasma osmolality is
breathing, cough and frothy sputum. She was admitted for preterm decreased during pregnancy which increases the
labor 24 hours ago. She is a non-smoker. She has received 6 liters of susceptibility to pulmonary edema. Common causes of
Lactated Ringers solution since admission. She is receiving acute pulmonary edema in pregnancy include tocolytic
magnesium sulfate and nifedipine. Vital signs are: 100.2F (37.9C); use, cardiac disease, fluid overload and preeclampsia. Use
respiratory rate 24; heart rate 110; blood pressure 132/85; pulse of multiple tocolytics increases the susceptibility of
oximetry is 97% on a non-rebreather mask. She appears in distress. pulmonary edema, especially with the use of isotonic
Lungs reveal bibasilar crackles. Uterine contractions are regular every fluids. Systemic vascular resistance is decreased during
three minutes. The fetal heart rate is 140 beats/minute. Labs show pregnancy. Women with chorioamnionitis are also more
white blood cell count 127,500/mL. Potassium and sodium are normal. likely to develop pulmonary edema, but this is not usually
Which of the following has most likely contributed to this patient's the main cause unless the patient is in septic shock and this
respiratory symptoms? patient does not have chorioamnionitis.
A. Initiate amnioinfusion
with sterile saline to dilute
the meconium-stained
amniotic fluid
B. Suction the oropharynx
and nasopharynx on the
perineum after the
delivery of the head but
before the delivery of the
shoulders
C. Suction the oropharynx
and nasopharynx on the
perineum immediately
after delivery before the
baby takes his first breath
D. Intubate the trachea
and suction meconium
and other aspirated
material from beneath the
glottis immediately after
delivery
E. Intubate the trachea
and suction meconium
and other aspirated
material from beneath the
glottis immediately after
delivery only if the infant
is depressed
27. A 24-year-old G1P0 woman has just delivered 37 week male twins. On your initial A. This case is suggestive of twin-twin
assessment, you notice twin A is large and plethoric, and twin B is small and pale. transfusion syndrome (TTTS). Polycythemia is a
A complete blood count (CBC) is obtained on both twins. What is the most likely common complication for the plethoric twin.
potential neonatal risk in this case? TTTS is a complication of monochorionic
pregnancies. It is characterized by an
A. Twin A is at high risk for polycythemia imbalance in the blood flow through
B. Twin A is at high risk for thrombocytopenia communicating vessels across a shared
C. Twin B is at high risk for thrombocytopenia placenta leading to under perfusion of the
D. Twin B is at high risk for tachycardia donor twin, which becomes anemic and over
E. Twin B is at high risk for hyperbilirubinemia perfusion of the recipient, which becomes
polycythemic. The donor twin often develops
IUGR and oligohydramnios, and the recipient
experiences volume overload and
polyhydramnios that may lead to heart failure
and hydrops.
28. A 24-year-old G1P0 woman presents in active labor at 39 weeks gestation. She E. This patient clearly has chorioamnionitis. The
reports leaking fluid for the last two days. She develops a temperature of 102.0F fetal tachycardia may be in response to the
(38.9C) and fetal heart rate is 180 beats/min with minimal variability. Maternal maternal fever. Fetal tachycardia coupled with
labs show: blood type O+; RPR non-reactive; HBsAg, negative; HIV negative; and minimal variability is a warning sign that the
GBS unknown. What will be the expected appearance of the baby at delivery? infant may be septic. A septic infant will
typically appear pale, lethargic and have a high
A. Vigorous, pink with normal temperature temperature.
B. Vigorous, pale with low temperature
C. Lethargic, pink with high temperature
D. Lethargic, pale with low temperature
E. Lethargic, pale with high temperature
29. A 24-year-old G4P2 woman at 34 weeks gestation complains of a cough and B. The increased minute ventilation during
whitish sputum for the last three days. She reports that everyone in the family pregnancy causes a compensated respiratory
has been sick. She reports a high fever last night up to 102F (38.9C). She denies alkalosis. Hypoventilation results in increased
chest pain. She smokes a half-pack of cigarettes per day. She has a history of PCO2 and the PO2 would be decreased if she
asthma with no previous intubations. She uses an albuterol inhaler, although she was hypoxic. A metabolic acidosis would have
has not used it this week. Vital signs are: temperature 98.6F (37C); respiratory a decreased pH and a low HCO3. The patient's
rate 16; pulse 94; blood pressure 114/78; peak expiratory flow rate 430 L/min symptoms are most consistent with a viral
(baseline documented in the outpatient chart = 425 L/min). On physical upper respiratory infection.
examination, pharyngeal mucosa is erythematous and injected. Lungs are clear
to auscultation. White blood cell count 8,700; arterial blood gases on room air
(normal ranges in parentheses): pH 7.44 (7.36-7.44); PO2 103 mm Hg (>100), PCO2
26 mm Hg (28-32), HCO3 19 mm Hg (22-26). Chest x-ray is normal. What is the
correct interpretation of this arterial blood gas?
A. Cesarean delivery
B. Vaginal delivery with no episiotomy
C. Vaginal delivery with a small, controlled
midline episiotomy
D. Forceps assisted delivery with no
episiotomy
E. Vacuum assisted delivery with no
episiotomy
32. A 25-year-old G2P1 woman at 38 weeks gestation B. If an intrauterine pressure catheter is placed, and a significant amount
presents to labor and delivery with spontaneous onset of vaginal bleeding is noted, the possibility of placenta separation or
of labor and spontaneous rupture of membranes. Her uterine perforation should be considered. In this case, withdrawing the
cervical exam was 5 cm dilated, 90 percent effaced and catheter, monitoring the fetus and observing for any signs of fetal
0 station at presentation two hours ago. Presently, the compromise would be the most appropriate management. If the fetal
patient is uncomfortable and notes strong contractions. status is found to be reassuring, then another attempt at placing the
The cervical examination is unchanged from admission. catheter may be undertaken.
You decide to place an intrauterine pressure catheter
(IUPC). On placement, approximately 300 cc of frank
blood and amniotic fluid flow out of the vagina. What is
the most appropriate next step in the management of
this patient?
A. Metformin
B. Docusate sodium
C. Ibuprofen
D. Oxycodone
E. Warfarin
38. A 28-year-old G0 woman presents with her husband for preconception C. Fanconi anemia, Tay-Sachs disease, Cystic
counseling. Her family is Ashkenazi Jewish from Poland. Her husband is 30 Fibrosis, and Niemann-Pick disease are all
years old and is also Jewish. They seek information about preconception and autosomal recessive conditions that occur at an
prenatal screening. The patient is at increased risk for having a fetus affected increased incidence in Jews of Ashkenazi descent.
with all of the following conditions except: The Beta thalassemia is seen mainly in
Mediterranean populations.
A. Fanconi anemia
B. Tay-Sachs disease
C. Beta thalassemia anemia
D. Cystic fibrosis
E. Niemann-Pick disease
39. A 28-year-old G1P0 internal medicine resident at 34 weeks gestation had A. The results of her PFT are consistent with normal
pulmonary function tests performed two days ago because she was feeling physiologic changes in pregnancy. Inspiratory
slightly short of breath. She is a non-smoker, and has no personal or family capacity increases by 15% during the third trimester
history of cardiac or respiratory disease. Vital signs are: respiratory rate 16; because of increases in tidal volume and inspiratory
pulse 90; blood pressure 112/70; temperature 98.6F (37C); oxygen reserve volume. The respiratory rate does not
saturation is 99% on room air. On physical examination: lungs are clear; change during pregnancy, but the TV is increased
abdomen non-tender; fundal height is 34 cm. The results of the pulmonary which increases the minute ventilation, which is
function tests are: inspiratory capacity (IC) increased; tidal volume (TV) responsible for the respiratory alkalosis in
increased; minute ventilation increased; functional reserve capacity (FRC) pregnancy. Functional residual capacity is reduced
decreased; expiratory reserve capacity (ERC) decreased; residual volume to 80% of the non-pregnant volume by term. These
(RV) decreased. What is the next best step in the evaluation of this patient? combined lead to subjective shortness of breath
during pregnancy.
A. Routine antenatal care
B. Chest x-ray
C. Arterial blood gas
D. Spiral CT of the lungs
E. Echocardiogram
40. A 28-year-old G1P0 woman is at 15 weeks gestation. Her husband's cousin C. Fragile X syndrome is the most common form of
has moderate mental retardation. The most common cause of inherited inherited mental retardation. The syndrome occurs
mental retardation in this patient's child would be? in approximately 1 in 3,600 males and 1 in 4,000 to
6,000 females. Down syndrome is genetic but the
A. Undiagnosed phenylketonuria (PKU) majority of cases are not inherited.
B. Neonatal hypothyroidism
C. Fragile X syndrome
D. Down syndrome
E. Autism
41. A 28-year-old G1P0 woman D. All the above can potentially be used to help date a pregnancy; however, ultrasound
presents for prenatal care. Her measurement of crown-rump length is considered the most reliable (+/- 4 to 5 days) in the first
periods have been irregular trimester. Other means to date the pregnancy include: fetal heart tones that have been
and she does not recall when documented for 20 weeks by a non-electronic fetoscope or for 30 weeks by Doppler; it has been
the last one occurred. She is 36 weeks since a positive serum or urine Beta-hCG pregnancy test was performed by a reliable
healthy and denies any laboratory; an ultrasound measurement of the crown-rump length obtained at six to twelve weeks
medical problems. The uterus supports a gestational age of at least 39 weeks; and an ultrasound obtained at 13-20 weeks
is 10 weeks in size and there confirms the gestational age of at least 39 weeks determined by clinical history and physical
are no adnexal masses. At this examination. Clearly, these means are not as useful in early pregnancy, but in confirming the length
point in time, what is the best of pregnancy. Serum progesterone levels are used to help establish if a pregnancy is progressing
way to date the pregnancy? normally and not an ectopic, miscarriage, or fetal demise.
A. Serum Progesterone
B. Quantitative serum Beta-
hCG
C. Ultrasound measurement,
gestational sac
D. Ultrasound measurement,
crown-rump length
E. Uterine size on pelvic exam
42. A 28-year-old G1P1 woman D. Engorgement commonly occurs when milk comes in. Strategies that may help include frequent
delivered three days ago and nursing, taking a warm shower or warm compresses to enhance milk flow, massaging the breast and
desires to breastfeed her hand expressing some milk to soften the breast, wearing a good support bra and using an
infant, but is having problems analgesic 20 minutes before breastfeeding.
since her milk came in with full
tender breasts. She is
uncomfortable and has
engorged breasts. Which of
the following strategies may
help relieve her discomfort?
A. Discontinue breastfeeding
for 24 hours to decrease the
milk supply
B. Cover the breast with cool
lettuce leaves
C. Increase the interval
between breastfeeding
sessions to decrease the milk
supply
D. Nurse every 1.5-3 hours
around the clock
E. Don't wear a bra until the
engorgement subsides
43. A 28-year-old G3P3 woman status post an C. Postpartum hemorrhage (PPH) is an obstetrical emergency that can
uncomplicated spontaneous vaginal delivery of 4150 follow vaginal or Cesarean delivery. Uterine atony is the most common
gram infant experiences profuse vaginal bleeding of 700 cause of PPH and occurs in one in every twenty deliveries. It is important
cc. Prior obstetric history was notable for a previous low to detect excessive bleeding quickly and determine an etiology and
uterine segment transverse Cesarean section, secondary initiate the appropriate treatment as excessive bleeding may result in
to transverse fetal lie. The patient had no antenatal hypovolemia, with associated hypotension, tachycardia or oliguria. The
problems. The placenta delivered spontaneously without most common definition of PPH is an estimated blood loss of greater
difficulty. Which of the following is the most likely cause than or equal to 500 ml after vaginal birth, or greater than or equal to
of this patient's hemorrhage? 1000 ml after Cesarean delivery.
A. Vaginal lacerations
B. Cervical lacerations
C. Uterine atony
D. Uterine dehiscence
E. Uterine rupture
44. A 29-year-old G1P1 woman had an uncomplicated B. Although the side lying position is a good one for breastfeeding, it is
vaginal delivery and breastfed immediately postpartum. important for mother and baby to be belly-to-belly in order for the
She has a significant amount of abdominal soreness infant to be in a good position to latch on appropriately, taking a large
secondary to a tubal ligation performed on postpartum part of the areola into its mouth. The pain experienced by the patient
day two. She is breastfeeding on her side with the baby from her tubal may be interfering with appropriate position and she
lying on her side, well away from the abdomen to should be counseled about a different, more comfortable position.
prevent pain at the incision site. She developed bleeding
and cracked nipples. Which of the following is the most
likely cause?
A. Polyhydramnios
B. Neonatal hypoglycemia
C. Intrauterine growth restriction
D. Preeclampsia
E. Fetal macrosomia
46. A 30-year-old G0 woman presents with her husband for C. Non-Hispanic white individuals, including Ashkenazi Jews, are at
preconception counseling. The patient is of Ashkenazi Jewish increased risk for being carriers for cystic fibrosis. The carrier
descent. Her husband is Irish. The patient has a brother who frequency is approximately 1/25 in the non-Hispanic white
has a child diagnosed with attention deficit hyperactivity population. Since the patient's husband is not of Ashkenazi Jewish or
disorder. Which of the following genetic diseases is the most French Canadian descent, he is not at increased risk for being a
likely to affect their future children? carrier for Tay-Sachs disease. The carrier frequency for Tay-Sachs
disease is estimated at 1/30 for Ashkenazi Jews. The gene occurs at
A. Canavan disease a much lower frequency (1 in 300) in most other populations.
B. Bloom syndrome Canavan disease, Bloom syndrome and Gaucher's disease occur at
C. Cystic fibrosis an increased incidence in the Ashkenazi Jewish population. The
D. Tay-Sachs disease carrier frequency for Canavan is 1:55, for Bloom 1:134, and for
E. Gaucher's disease Gaucher is approximately 1/15 in Ashkenazi Jews.
47. A 30-year-old G1P0 woman with type 1 diabetes mellitus A. Women with poorly controlled diabetes immediately prior to
presents at 10 weeks gestation for a routine visit. She smokes conception and during organogenesis have a four- to eight-fold risk
a half a pack of cigarettes per day. Her hemoglobin A1C of having a fetus with a structural anomaly. The majority of lesions
level is 9.7. What structural anomaly is the fetus at highest involve the central nervous system (neural tube defects) and the
risk of developing? cardiovascular system. Genitourinary and limb defects have also
been reported. Although caudal regression malformation occurs at
A. Cardiac anomalies an increased incidence in individuals with diabetes, this condition is
B. Caudal regression malformation very rare.
C. Hydrocephalus
D. Microcephaly
E. Limb reductions
48. A 30-year-old G1P1 woman is breastfeeding her baby and E. While prolactin is responsible for milk production, oxytocin is
feels there is not enough milk. She is pumping in order to responsible for milk ejection. Production of oxytocin is stimulated by
improve the supply of milk. You tell her that more frequent suckling which works better than a breast pump for stimulating the
suckling would be better as it will stimulate which of the secretion of milk. Cortisol and insulin act in concert with other
following hormones? hormones to stimulate the growth and development of the milk-
secreting apparatus.
A. Progesterone
B. Insulin
C. Cortisol
D. Prolactin
E. Oxytocin
49. A 30-year-old G1P1 woman who underwent an urgent C. The most significant risk factor for developing postpartum
vacuum extraction of a baby girl two months ago is depression is the patient's prior history of depression. Other risk
experiencing persistent depressive symptoms suggestive of factors for postpartum depression include marital conflict, lack of
postpartum depression. She is recently divorced and has no perceived social support from family and friends, having
immediate family or close friends. She works as a mechanic contemplated terminating the current pregnancy, stressful life
in a local garage and is planning on going back to school. events in the previous twelve months, and a sick leave in the past
She contemplated terminating the pregnancy but ultimately twelve months related to hyperemesis, uterine irritability or
decided to have the baby despite no support from her ex- psychiatric disorder.
husband. She has a history of depression in the past but has
not required any medications for the last three years. Which
of the following is her most significant risk factor for
postpartum depression?
A. Single parent
B. Consideration to terminate the pregnancy
C. Personal history of depression
D. Urgent delivery
E. Social isolation
50. A 30-year-old G2P0 woman at 38 weeks gestation has just B. Small babies are more common with type 1 diabetes than with
delivered a male infant. She has a history of type 1 diabetes gestational diabetes, and the blood sugar level of all newborns of
since age 11. Maternal labs show: blood type B+; RPR non- diabetic mothers should be monitored closely after delivery, as
reactive; HBsAg negative; HIV negative; and GBS negative. they are at increased risk for developing hypoglycemia.
She had moderate control of blood sugar during her Macrosomic (large) infants are typically associated with gestational
pregnancy. Which of the following would be the most likely diabetes.
finding in the newborn?
A. Uterine fibroid
B. Fetal hydrocephalus
C. Polyhydramnios
D. Macrosomia
E. 42 weeks gestation
52. A 32-year-old G1 woman C. Amniocentesis is a diagnostic test that may detect Down syndrome as well as other chromosomal
with an IVF conceived abnormalities. Cell-free DNA testing detects over 99% of cases of Down syndrome. The first trimester
pregnancy at 12 weeks screen, which consists of a nuchal translucency and maternal serum PAPP-A and beta-hCG, yields an
gestation has a slightly 85% detection rate for Down syndrome. The NT is the measurement of the fluid collection at the back
increased fetal nuchal of the fetal neck in the first trimester. A thickened NT may be associated with fetal chromosomal and
translucency (3.0 mm), but structural abnormalities as well as a number of genetic syndromes. Patients who desire non-invasive
her first trimester screen assessment of their risk for aneuploidy can have first trimester screen (a fetal nuchal translucency (NT)
shows no increased risk for measurement and a maternal serum PAPP-A) and a second trimester quadruple screen. The
Down syndrome or Trisomy sequential screen which combines the first trimester screen with a quadruple screen yields a 95%
18. Still concerned about the detection rate for Down syndrome at a 5% false-positive rate. Since the fetus in this case had a
increased nuchal thickened NT, this patient should be scheduled to have a detailed fetal ultrasound and
translucency, the patient echocardiogram at 18-20 weeks to rule out anomalies. However, it is not possible to diagnose a
requests additional testing chromosomal abnormality with an ultrasound. Similarly, although genetic sonograms (targeted
to exclude chromosomal sonogram) focus on markers associated with Down syndrome, they are not diagnostic. Approximately
abnormalities. Which of the 50% of cases of Down syndrome do not have ultrasound findings. Of note, the American Congress of
following is the next best Obstetrics and Gynecology (ACOG) recommends that all patients be offered aneuploidy screening
step to rule out a and invasive prenatal diagnosis as indicated.
chromosomal abnormality in
this patient?
A. Depot medroxyprogesterone
B. Combined estrogen-progestin contraceptives
C. Tubal ligation
D. Intrauterine device (IUD)
E. Essure (Bilateral occluding tubal coils)
59. A 34-year-old G1P0 woman at 39 weeks gestation D. This patient is having late decelerations. Late decelerations are
presents in active labor. Her cervical examination an associated with uterine contractions. The onset, nadir, and recovery of the
hour ago was 5 cm dilated, 90 percent effaced and 0 decelerations occur, respectively, after the beginning, peak and end of
station. She just had spontaneous rupture of the contraction. Late decelerations are associated with uteroplacental
membranes and is found to be completely dilated with insufficiency. A rapid change in cervical dilation and descent are not
the fetal head is at +3 station. The fetal heart rate associated with late decelerations. Umbilical cord compression is
tracing is shown below. What is the most likely etiology associated with variable decelerations. Oligohydramnios can increase a
for these decelerations? patient's risk of having umbilical cord compression; however, it does not
cause late decelerations. Head compression is associated with early
(late decels) decelerations.
A. Oligohydramnios
B. Rapid change in descent
C. Umbilical cord compression
D. Uteroplacental insufficiency
E. Head compression
60. A 34-year-old G2P1 woman is 40 weeks gestation. She E. This patient has an umbilical cord prolapse. Although fetal surveillance is
was admitted to labor and delivery in active labor 2 reassuring, the most appropriate management is to continue to elevate the
hours ago. Her cervix was 6 cm dilated and 100% fetal head with a hand in the patient's vagina and call for assistance to
effaced on admission. Her fetus was vertex and - 3 perform a Cesarean delivery. It is important to elevate the fetal head in an
station. You are called to examine the patient after she attempt to avoid compression of the umbilical cord. Once an umbilical
experiences spontaneous rupture of membranes. The cord prolapse is diagnosed, expeditious arrangements should be made to
cervix is completely dilated and the fetal head is perform a cesarean section. It is not appropriate to replace the umbilical
occiput anterior (OA) at +1 station. You palpate a 5 cm cord into the uterus or allow the patient to continue to labor or perform a
long section of umbilical cord in the patient's vagina. forceps-assisted vaginal delivery.
The fetal heart tracing is reassuring. The baseline is
130 beats per minute. There are multiple accelerations
and no decelerations. The patient is having regular
uterine contractions every 2-3 minutes. She has an
epidural and is not feeling the contractions. What is
the most appropriate next step in the management of
this patient?
A. Pulmonary embolism
B. Mitral valve stenosis
C. Physiologic dyspnea of pregnancy
D. Peripartum cardiomyopathy
E. Anemia
63. A 34-year-old G4P2 woman at 18 weeks gestation presents with A. Thyroid binding globulin (TBG) is increased due to
fatigue and occasional headache. She has a sister with Grave's increased circulating estrogens with a concomitant increase
disease. On physical exam, vital signs are normal. BMI is 27. Thyroid in the total thyroxine. Free thyroxine (T4) remains relatively
is difficult to palpate due to her body habitus. The remainder of her constant. Total triiodothyroxine (T3) levels also increase in
exam is unremarkable. Thyroid function studies show: pregnancy while free T3 levels do not change. In a pregnant
patient without iodine deficiency, the thyroid gland may
Results Reference Range increase in size up to 10%. This patient's thyroid function is
TSH 1.8 mU/L 0.30 - 5.5 mU/L normal for pregnancy, and her symptoms of fatigue can be
Free T4 1.22 ng/dL 0.76 - 1.70 ng/dL explained by other physiologic changes in pregnancy,
Total T4 14.2 ng/dL 4.9 - 12.0 ng/dL including anemia, difficulty with sleep, and increased
Free T3 3.4 ng/dL 2.8 - 4.2 ng/dL metabolic demand.
Total T3 200 ng/dL 80 - 175 nd/dL
What is the next best step in the management of this patient?
A. Aerobic streptococcus
B. Anaerobic streptococcus
C. Aerobic staphylococcus
D. Anaerobic staphylococcus
E. Aerobic and anaerobic bacteria
65. A 35-year old G2P1 woman is at 11 weeks D.
gestation. She had a triple screen with her last All of the tests screen for trisomy 21 and trisomy 18. Cell-free DNA screening has a
pregnancy and would like to have aneuploidy trisomy 21 detection rate of over 99% at a 0.2% false-positive rate. The other
screening with the current pregnancy. Which options may also be used to screen for trisomy 21. Detection rates provided at a
of the following screening tests will provide 5% false positive screen rate.
the highest detection rate for trisomy 21 for First trimester combined test: first trimester nuchal translucency, PAPP-A
this patient? (pregnancy associated plasma protein A) and Beta-hCG - 85% Detection Rate
Triple screen: second trimester AFP (alpha fetoprotein), Beta-hCG, uE3
A. First trimester combined test (unconjugated estriol) - 69% Detection Rate
B. Sequential screen Quad screen: (second trimester Triple screen + inhibin A) - 81% Detection Rate
C. Quad screen Sequential screen: (first trimester NT and PAPP-A + second trimester quad
D. Cell-free DNA screen screen) - 93% Detection Rate
E. Serum integrated screen Serum integrated screen, when unable to obtain nuchal translucency: (first
trimester PAPP-A + second trimester quad screen) - 85-88% Detection Rate
66. A 35-year-old G3P2 woman presents for her D. The patient's gestational age based on her LMP and the findings on physical
initial prenatal care visit at 15 weeks gestation, exam are discordant. In this case, the most reliable method of confirming
according to her last menstrual period. She gestational age is a dating ultrasound. A quantitative Beta-hCG will not reliably
reports that a home pregnancy test was predict the gestational age. The uterine size on physical exam is not the most
positive about five weeks ago. Review of her accurate way to date a pregnancy. An ultrasound performed between 14 and 15
history is unremarkable and her entire family 6/7 weeks gestation should be used to date the pregnancy if there is greater than
is in good health. Physical examination reveals a 7 day discrepancy from the menstrual dates or more than a 10 day discrepancy if
a ten-week size uterus. Which of the following the ultrasound is performed between 16 and 21 6/7 weeks. . First trimester
is the most appropriate next step in ultrasound provides the most accurate assessment of gestational age and can give
establishing this pregnancy's gestational age? an accurate estimated date of confinement (EDC) to within 3-5 days.
A. 0.1%
B. 1%
D. 10%
E. 15%
C. 5%
68. A 35-year-old G4P3 woman comes in for a C. In addition to the more common symptoms of depression, the postpartum patient
postpartum visit. She had a normal may manifest a sense of incapability of loving her family and manifest ambivalence
uncomplicated vaginal delivery two weeks toward her infant. Anhedonia is an inability to experience pleasure from normally
ago. She has a history of postpartum pleasurable life events such as eating, exercise, and social or sexual interaction.
depression, which required treatment with
antidepressants with her last pregnancy.
Which of the following signs or symptoms
of postpartum depression are most useful
to distinguish it from postpartum blues and
normal changes that occur after delivery?
A. Anhedonia
B. Crying spells
C. Ambivalence toward the newborn
D. Sleeplessness
E. Weight loss
69. A 35-year-old G5P4 woman status post E. The most likely complication she will experience is future pregnancy. The failure
vaginal delivery desires postpartum tubal rate associated with surgical sterilization is approximately one percent. Approximately
ligation. In obtaining informed consent, one-third of pregnancies after tubal ligation are ectopic. The existence of a "post-
which of the following is the most likely risk tubal ligation syndrome" in which disruption of blood flow in the area of the fallopian
associated with this procedure? tubes leads to menstrual dysfunction and dysmenorrhea has not been substantiated.
Tubal ligation appears to have a protective effect on ovarian cancer incidence. There
A. Chronic cyclic pain with menstrual cycles is no proven association between decreased sexual enjoyment and tubal ligation.
B. Increased risk for ovarian cancer Tubal ligations may be performed under regional or general anesthesia. Postpartum
C. Decreased enjoyment with sexual tubal ligations are generally performed using a spinal or epidural anesthesia. The risk
intercourse of aspiration are low and range from 1/1000 to 1/14,000.
D. Aspiration with general anesthesia
E. Unplanned pregnancy
70. A 36-year-old woman requests prenatal B. Chorionic villus sampling (CVS) is a prenatal test that can detect genetic and
diagnosis. She is healthy and excited about chromosomal abnormalities of a fetus. The loss rate with amniocentesis is quoted as
finally getting pregnant. She is interested in 0.5% vs. ~1 to 3% for chorionic villus sampling. CVS is performed between 10 and 12
genetic counseling and asks about the weeks gestation, while amniocentesis is performed after 15 weeks. Early CVS (<10
advantages of chorionic villus sampling weeks gestation) is associated with an increase in rare limb abnormalities. It is more
versus amniocentesis. Which of the likely that a CVS will involve multiple attempts - a failure to obtain an adequate
following is true when chorionic villus sample of cells and the woman requiring a repeat test later on - when compared with
sampling is compared to amniocentesis? amniocentesis. Pregnancies complicated by isoimmunization can be followed by serial
assessment of the amniotic fluid for bilirubin.
A. Reduced post-procedure loss rate
B. Performed earlier
C. More likely to obtain an adequate
sample
D. Lower rate of procedure related birth
defects
E. Less risk of alloimmunization
71. A 37-year-old G3P2 woman presents C. CVS is generally performed at 10-12 weeks gestation. The procedure involves sampling of
with her husband at 11 weeks the chorionic frondosum, which contains the most mitotically active villi in the placenta. CVS
gestation for genetic counseling due can be performed using a transabdominal or transcervical approach. The sampled placental
to advanced maternal age. The tissue may be analyzed for fetal chromosomal abnormalities, biochemical, or DNA-based
patient and her husband are studies including testing for the mutations associated with cystic fibrosis. CVS cannot be used
interested in chorionic villus to detect neural tube defects. Omphaloceles and neural tube defects are generally
sampling (CVS). In addition to diagnosed using prenatal ultrasound. Both of these conditions are associated with an
obtaining a karyotype, which of the increased MSAFP (maternal serum alpha-fetoprotein).
following can be detected with this
procedure?
A. Spina bifida
B. Fetal omphalocele
C. Cystic fibrosis
D. Anencephaly
E. Fetal cardiac anomaly
72. A 38-year-old G1P0 woman presents A. The initial evaluation of patients presenting to the hospital for labor includes a review of
to the hospital at 39 weeks in early the prenatal records with special focus on the antenatal complications and dating criteria, a
labor. She has had routine prenatal focused history and a targeted physical examination to include maternal vital signs and fetal
care and no antepartum heart rate, and abdominal and pelvic examination. A speculum exam with a nitrazine test to
complications to date. She reports confirm rupture of membranes is indicated if the patient's history suggests this, or if a patient
good fetal movement and denies is uncertain as to whether she has experienced leakage of amniotic fluid. Performing a fetal
vaginal bleeding and leakage of ultrasound is not a routine part of an assessment in a patient who may be in early labor. A
fluid. What is the next best step in prenatal ultrasound may be used in cases to determine fetal presentation, estimated fetal
the initial assessment of this patient? weight, placental location or amniotic fluid volume.
A. Physical examination
B. Nitrazine test
C. Fetal ultrasound
D. Biophysical profile
E. Contraction stress test
73. A 38-year-old G1P1 woman who C. Signs that a baby is getting sufficient milk include 3-4 stools in 24 hours, six wet diapers in
delivered by a Cesarean delivery 24 hours, weight gain and sounds of swallowing.
three weeks ago presents to the
clinic with concerns that the baby is
not getting enough milk and is fussy.
She reports that she is feeding on
demand and not supplementing.
Which of the following is indicative
that the baby is getting adequate
milk?
A. Normal puerperium
B. Postpartum blues
C. Postpartum depression
D. Anxiety disorder
E. Bipolar disorder
79. An African-American couple comes to you for D. Screening for carriers of both alpha and beta thalassemia is possible by
preconception counseling. Neither one has any evaluation of red cell indices. Although solubility tests for hemoglobin S or
significant family or genetic history. Based on their sickle cell preparations can be used for screening, hemoglobin
African-American descent, which of the following electrophoresis is definitive and preferable because other
blood tests would you recommend? hemoglobinopathies can also be detected including hemoglobin C trait and
thalassemia minor. Although sickle cells can be identified on a blood smear in
A. MCV and CBC individuals with sickle cell disease, the cells may be absent in individuals with
B. Sickle cell preparation and CBC milder types of sickle cell disease and even in some individuals with severe
C. Peripheral blood smear and CBC sickle cell disease. Evaluation of a peripheral smear is not useful in detecting
D. Hemoglobin electrophoresis and CBC carriers for sickle cell disease.
E. Sickle cell preparation with a hemoglobin
electrophoresis, if the sickle preparation is
abnormal
80. At one minute of life, an infant has a heart rate E. Heart rate= 2, Respiratory rate= 2, Reflex = 2, Activity =2, Color =1. Therefore,
greater than 120 beats/minute, is crying, has the one-minute APGAR score is 9.
acrocyanosis, gags when suctioned and is
vigorously moving all four extremities. What is the
APGAR score for this infant?
A. 5
B. 6
C. 7
D. 8
E. 9
Unit 2: Obstetrics - B. Abnormal Obstetrics
Study online at quizlet.com/_2iif08
1. A 16-year-old G1P0 African-American female presents at C. The two most common causes of anemia during pregnancy and the
eight weeks gestation for prenatal care. She reports puerperium are iron deficiency and acute blood loss. Classical
occasional spotting but denies pain or fever. The morphological evidence of iron-deficiency anemia includes
laboratory reports hemoglobin of 8 g/dL and a peripheral erythrocyte hypochromia and microcytosis. Serum ferritin levels are
smear reveals hypochromia and microcytosis. Which of the lower than normal and there is no stainable bone marrow iron on
following is the most likely diagnosis for this patient? examination of a bone marrow aspirate. The spotting she reports
would not lead to anemia due to blood loss
A. Sickle cell anemia
B. Folate deficiency
C. Iron deficiency
D. -thalassemia
E. Acute blood loss
2. A 17-year-old G1P0 female at 39 weeks gestation presents E. Regardless of disease severity, the only definitive therapy for
with increased swelling in her face and hands over the last preeclampsia is delivery of the fetus and placenta. This solution can
two days. Her blood pressure is 155/99. She has 2 plus occasionally be delayed in the setting of stable disease (mild or
pitting edema of the lower extremities. A 24-hour urine severe) when it occurs at an extremely early gestational age. Fluid
collection shows 440 mg of protein. What is the next best management must be monitored closely in this person. Magnesium
step in the management of this patient? sulfate is the mainstay of therapy during labor and for 24 hours
postpartum to lower the seizure threshold in women with severe
A. Fluid restriction disease. Low-dose aspirin may have some benefit in decreasing the risk
B. Magnesium sulfate of preeclampsia in a subset of high-risk patients. Hydralazine is often
C. Furosemide the antihypertensive agent of choice for controlling elevated blood
D. Hydralazine pressures in the acute setting.
E. Delivery
3. A 17-year-old G1 woman at 24 weeks gestation presents C. Cervicitis caused by chlamydia, gonorrhea, trichomonas or other
with vaginal bleeding. She denies any pain, cramping or infections can present with vaginal bleeding. The cervix is much more
dysuria. She reports last having intercourse three weeks vascular during pregnancy and inflammation can lead to bleeding.
ago. Prenatal care and labs have been unremarkable. Her Evaluation for other causes of bleeding must be completed and then
vital signs are normal and she is afebrile. Pelvic ultrasound treatment for the infection should be initiated. The patient does not
reveals a fundal placenta and viable fetus. Abdominal give any history of trauma and cancer is unlikely because of her age.
examination is unremarkable. Vaginal examination reveals a She is not in labor, and a bloody show associated with cervical
uniformly friable cervix with a small amount of blood in the dilatation is not consistent with the history provided. Threatened
vault. Digital examination reveals a firm, closed cervix. abortion occurs during the first trimester.
What is the most likely diagnosis that explains the
bleeding?
A. Trauma
B. Cervical cancer
C. Cervicitis
D. Bloody show
E. Threatened abortion
4. A 17-year-old G2P0 female has severe right lower quadrant pain. Her last B. This patient has a ruptured ectopic pregnancy
normal menstrual period was seven weeks ago. She notes that last night she until proven otherwise. Her vital signs, examination
began having suprapubic pain that radiated to her right lower quadrant. This and anemia are consistent with an intra-abdominal
morning, the pain awoke her from sleep. She has had no vaginal bleeding, no bleed. Exploratory laparoscopy/laparotomy is
nausea or vomiting. The patient's history is notable for two first trimester indicated at this point. Conservative management
elective abortions and a history of chlamydia treated twice. Vital signs are with observation, serial examinations or repeat
blood pressure 90/60; pulse 99; respirations 22; and temperature 98.6F Beta-hCG testing could be dangerous in a patient
(37C). On physical exam, the patient is noted to be curled on a stretcher in a suspected of having a ruptured ectopic pregnancy.
fetal position and says she hurts too much to move. She has rebound and Medical management (methotrexate) is not used in
voluntary guarding on abdominal examination. She has severe cervical motion a patient with an acute surgical abdomen. Dilation
tenderness and rectal tenderness. Her Beta-hCG level is 2500 mIU/ml; and curettage would not be the next step in
hematocrit 24%; and urinalysis negative. Ultrasound shows no intrauterine management and might only be considered in this
pregnancy, a right adnexal mass that measures 6 x 2 cm, and a moderate scenario after the patient's abdomen was explored.
amount of free fluid in the cul de sac. Which of the following is the most
appropriate next step in the management of this patient?
A. Anxiolytics
B. -blockers
C. Calcium-channel blockers
D. Digitalis
E. No treatment needed at this time
9. A 19-year-old G1P0 woman at 28 weeks gestation C. In most cases, preterm labor is idiopathic (i.e. no cause can be
comes to labor and delivery because of the onset of identified). Dehydration and uterine distortion (from uterine fibroids or
contractions. The patient describes the contractions as structural malformations) can be associated with preterm labor. In some
progressively becoming more painful, each lasting 40 cases, preterm labor is due to iatrogenic causes; for example, when a
seconds and now occurring every five minutes. She physician induces a preterm patient who has severe preeclampsia. Fetal
reports good fetal movement and does not have any anomalies typically do not cause preterm labor. Cervical incompetence is
bleeding or leakage of fluid. On evaluation in triage, it usually diagnosed earlier in the second trimester and is associated with
is noted that she is having regular contractions, painless cervical dilation.
approximately every five minutes, has intact
membranes and her cervical exam is 3 cm dilated and
50% effaced. What is the most frequent cause of this
condition?
A. Dehydration
B. Fetal anomalies
C. Idiopathic
D. Uterine fibroids
E. Cervical incompetence
10. A 19-year-old G1P0 woman at 39 weeks gestation presents in labor. A. Variable decelerations are reflex mediated usually
She denies ruptured membranes. Her prenatal course was associated with umbilical cord compression as a result of
uncomplicated and ultrasound at 18 weeks revealed no fetal cord wrapped around fetal parts, fetal anomalies or
abnormalities. Her vital signs are: blood pressure 120/70; pulse 72; oligohydramnios. The presence of light meconium-stained
temperature 101.0 F (38.3 C); fundal height 36 cm; and estimated fluid is not associated with a specific fetal heart rate tracing.
fetal weight of 2900 gm. Cervix is dilated to 4 cm, 100% effaced and Uteroplacental insufficiency is associated with late
at +1 station. She receives 10 mg of morphine intramuscularly for pain decelerations. Maternal drugs may cause loss of variability.
and soon after has spontaneous rupture of the membranes. Light
meconium-stained fluid was noted and, five minutes later, the fetal
heart rate tracing revealed variable decelerations with moderate
variability. What is the most likely cause for the variable
decelerations?
A. Ethnicity
B. Smoking
C. Previous premature rupture of membranes
D. Cervical length
E. Genital tract infections
20. A 19-year-old G2P1 woman at 28 weeks gestation has been diagnosed B. Magnesium sulfate works by competing with calcium
with preterm labor. Her physician has chosen to treat her with entry into cells. Beta-adrenergic agents work by
magnesium sulfate. By what mechanism of action does magnesium increasing cAMP in the cell, thereby decreasing free
sulfate work as a tocolytic? calcium. Prostaglandin synthetase inhibitors, such as
Indomethacin, work by decreasing prostaglandin (PG)
A. Decreases prostaglandin (PG) production production by blocking conversion of free arachidonic
B. Competes with calcium for entry into cells acid to PG. Calcium channel blockers prevent calcium
C. Increases cAMP in the cell entry into muscle cells by inhibiting calcium transport.
D. Blocks calcium entry into muscle cells
E. Inhibits calcium transport
21. A 19-year-old G2P1 woman presents with vaginal spotting and uterine B. Transvaginal ultrasound will most likely show an
cramping. Her last normal menstrual period was six weeks ago and she intrauterine pregnancy. The Beta-hCG level is above the
began spotting three days ago. She has no history of sexually discriminatory zone for ultrasound (2000 mIU/ml), and
transmitted infections. Her vital signs are blood pressure 120/70; pulse the level has doubled in 48 hours. Additionally, the
78; respirations 20; and temperature 98.6F (37.0C). On pelvic progesterone level is within expected range for a normal
examination, she has no cervical motion tenderness, her uterus is pregnancy (>25 ng/ml suggests healthy pregnancy) and
normal size and non-tender; no adnexal masses are palpable. up to 30% of all normal pregnancies experience first
Quantitative Beta-hCG 48 hours ago was 1500 mIU/ml. Currently, Beta- trimester spotting/bleeding. The findings of debris in the
hCG is 3100 mIU/ml. Progesterone is 26 ng/ml; hematocrit is 38%; and uterus, an empty uterus, with or without an adnexal mass,
urinalysis is normal. What is the most likely finding on transvaginal or free fluid (suggesting hemoperitoneum) would not be
ultrasound? anticipated.
A. Debris in uterus
B. Viable intrauterine pregnancy
C. Adnexal mass, empty uterus
D. No adnexal mass, empty uterus
E. Non-viable intrauterine pregnancy
22. A 19-year-old G3P0 woman at 39 weeks gestation with spontaneous D. The baseline fetal heart rate is >160 with no
rupture of membranes for 13 hours presented to labor and delivery. accelerations or variability. There are regular
Her vital signs are: blood pressure 120/70; pulse 72; afebrile; fundal contractions. Prolonged periods of fetal tachycardia are
height 36 cm; and estimated fetal weight of 2700 gm. Cervix is dilated frequently found with maternal fever or chorioamnionitis.
to 1 cm, 50% effaced, -2 station. Which statement best describes the
tracing seen below?
(fetal baseline in 170s, flattish line til end then irregular decel; CTX
regular)
A. Exploratory laparoscopy
B. Treat with methotrexate
C. Treat with mifepristone
D. Expectant management
E. Repeat ultrasound in one week
25. A 20-year-old G1P1 woman delivered her first baby 24 hours C.
ago. Delivery was uncomplicated and she had an epidural
placed for analgesia at 5 cm of cervical dilation. Earlier in the Likely meningitis, perhaps from the epidural.
afternoon, she was complaining of a headache and was given
ibuprofen. Three hours later, she complained of increasing
headache, photophobia and nausea. She denies heavy
bleeding. Vital signs are pulse 110; respirations 20;
temperature 101.5 F (38.6 C); and blood pressure 100/50.
Physical examination reveals obvious distress, as she has her
eyes covered and pain when she moves her neck. Her lungs
are clear and heart has a regular rate. Her abdomen is
nontender, and uterine fundus is easily palpable just below
the umbilicus and is nontender. Her extremities reveal no
erythema, swelling or tenderness. Which of the following
would most helpful to establish a diagnosis in this patient?
A. Chest x-ray
B. Urinalysis
C. Lumbar puncture
D. CBC with differential
E. Pelvic ultrasound
26. A 20-year-old G1 woman at 40 weeks gestation presents to labor C. The patient is in the latent phase of labor and has not yet
and delivery complaining of painful contractions every 3-4 reached the active phase (more than 4 cm). A prolonged latent
minutes for the last eight hours. Cervical examination on phase is defined as >20 hours for nulliparas and >14 hours for
admission was 2 centimeters dilated, 90% effaced and 0 station. multiparas, and may be treated with rest or augmentation of
Three hours later, her exam is unchanged. The patient is still labor. Artificial rupture of membranes is not recommended in
having contractions every 3-4 minutes. She is discouraged about the latent phase as it places the patient at increased risk of
her lack of progress. Which of the following is the most infection. Cervical dilation or laminaria placement are not
appropriate next step in the management of this patient? indicated.
A. Laminaria placement
B. Artificial rupture of membranes
C. Counseling about latent phase of labor and rest
D. Manual cervical dilation
E. Cesarean section for arrest of labor
27. A 20-year-old G2P1 woman at 28 weeks gestation presents to D. This patient has a fever, a tender fundus, and elevated white
labor and delivery with contractions every four minutes. On blood cell count, which are concerning for an intra-amniotic
physical examination, her vital signs are: temperature 101F infection. Delivery is warranted and in the case of reassuring
(38.3C); heart rate 120; respiratory rate 18; and blood pressure heart tones, there are no contraindications for labor induction
110/65. Her uterine fundus is tender and the rest of the physical and a Cesarean section is not indicated at this time. Tocolytics
exam is normal. Her cervix is dilated 1 cm and is 50% effaced. The should not be used in the case of an intra-amniotic infection.
fetus is in vertex presentation. Fetal heart tones are in the 150s Conservative management with observation would delay
with a Category I tracing. Her white blood cell count (WBC) is diagnosis and would not be appropriate. A contraction stress
18,000/mcL. Which of the following is the most appropriate next test is not indicated since the patient is already contracting
step in the management of this patient? with reassuring fetal heart tones.
A. Observation
B. Tocolysis
C. Contraction stress test
D. Labor induction
E. Cesarean section
28. A 20-year-old G2P1 woman is at 41 weeks gestation. Her prenatal D. Postterm pregnancies are associated with macrosomia,
course and past medical history are unremarkable. She has not oligohydramnios, meconium aspiration, uteroplacental
had any complications with her pregnancy and fetal surveillance insufficiency and dysmaturity. Although postterm infants are
is reassuring. Which of the following complications is most likely larger than term infants and have an increased incidence of
to occur in this pregnancy? fetal macrosomia, there is no evidence to support induction of
labor as a preventive measure for macrosomia in these cases.
A. Preeclampsia There is no associated risk for preeclampsia in postterm
B. Retained placenta gestations.
C. Postpartum hemorrhage
D. Macrosomia
E. Placenta abruption
29. A 21-year-old G1P0 woman presents to labor and delivery at A. This patient is most likely to have the autosomal dominant Factor
39 weeks gestation with a chief complaint of decreased fetal V Leiden (FVL) mutation based on her history. FVL is the most
movement over the last two days. An ultrasound shows a common inherited thrombophilic disorder affecting approximately
fetus with biometry consistent with 34 weeks gestation with 5% of Caucasian women in the United States. It is a point mutation
no cardiac activity. The head circumference and biparietal which alters factor V making it resistant to inactivation by protein C.
diameter are consistent with 37 weeks and the abdominal The thrombophilic effect of a FVL mutation has been clearly
circumference, femur and humerus lengths are all lagging by established. Heterozygosity for FVL is associated with a five- to ten-
approximately five weeks. The amniotic fluid volume is fold increased risk of thrombosis, while homozygosity is associated
slightly decreased. No other abnormalities are identified. with an 80-fold increased risk. The FVL mutation is associated with
The patient's medical history is notable for a deep venous obstetric complications including stillbirth, preeclampsia, placental
thrombosis which she had three years ago while she was abruption and IUGR. Fetuses with Trisomy 18 are likely to have
using oral contraceptives. She had a reassuring quad screen. congenital anomalies that are detectable on prenatal ultrasound.
She denies any history of fever or viral illnesses during the Over 90% of cases of trisomy 21 and 18 may be detected with the
pregnancy. She works as a preschool teacher. The patient quad screen. A congenital parvovirus infection associated with a
had a fetal ultrasound at 20 weeks gestation. At that time all fetal demise would likely cause hydrops in the fetus which would be
of the fetal anatomy was well-visualized and no identified on ultrasound. Although poorly controlled diabetes
abnormalities were identified. Which of the following is the mellitus are associated with fetal demise, they are not the most likely
most likely explanation for the fetal demise in this case? etiologies in this patient whose presentation is classic for the FVL
mutation.
A. Trisomy 21
B. Trisomy 18
C. Poorly controlled undiagnosed diabetes mellitus
D. Fetal parovirus infection
E. Factor V Leiden mutation
30. A 21-year-old G1 woman at 36 weeks gestation presents with B. This patient is undergoing a placental abruption, with a
sudden onset of abdominal pain and bleeding. She smokes a deteriorating fetal condition. An emergent Cesarean delivery is
pack of cigarettes a day, but otherwise her pregnancy has necessary. The mother risks excessive blood loss, DIC and possible
been uncomplicated. She takes no medications other than hysterectomy. The fetus risks neurological injury from anoxia or
prenatal vitamins. Her blood pressure is 150/90; pulse 90; death. Risk factors for abruption include smoking, cocaine use,
and she is afebrile. Her uterus is tense and very tender. abdominal trauma, chronic hypertension, multiparity and prolonged
Pelvic ultrasound shows the placenta to be posterior and premature rupture of membranes. Since immediate delivery is
fundal, with a cephalic presentation of the fetus. Cervical needed, amniotomy, induction, or tocolysis are not appropriate. A
examination reveals no lesions, blood coming through the os double set-up examination (performed in the operating room with a
and is one centimeter dilated. Fetal heart tones have a Cesarean section team scrubbed and ready) is not indicated, since
baseline of 150, with a Category III fetal heart rate tracing. the ultrasound determined the location of the placenta to be fundal.
Tocometer reveals contractions every 30-45 seconds. Which
of the following is the most appropriate next step in the
management of this patient?
A. Amniotomy
B. Cesarean delivery
C. Induction of labor
D. Tocolysis
E. A double set-up examination
31. A 22-year-old G1P0 woman at 39-weeks gestation B. Prematurity, multiple gestation, genetic disorders, polyhydramnios,
presents in active labor. Her pregnancy is hydrocephaly, anencephaly, placenta previa, uterine anomalies and uterine
complicated by diet-controlled gestational fibroids are all associated with breech presentation.
diabetes. She has a history of uterine fibroids. On
examination, she is found to be 4 cm dilated in
breech presentation. An ultrasound confirms the
breech presentation, amniotic fluid index is 5, and
the estimated fetal weight is 3900 g. Which of the
following is the most likely cause of the breech
presentation in this patient?
A. Gestational diabetes
B. Uterine fibroids
C. Oligohydramnios
D. Macrosomia
E. Gravidity
32. A 22-year-old G1P0 woman currently at 38 weeks C. Allowing the parents when to decide to deliver can help the bereavement
gestation complains of decreased fetal movement. process. Keeping the patient adequately anesthetized during the labor and
Ultrasound reveals a 38-week gestation with no delivery as well as letting the parents hold the baby for as long as they desire
cardiac activity. The parents are upset and want to also helps them grieve. Whether to have care on the maternity floor needs to
know the next steps. Which of the following would be the parents' decision as well. Offering an autopsy to determine the cause of
be most helpful to aide the bereavement process? death as well as having someone taking pictures and keeping mementos for
the parents is helpful.
A. Minimize analgesia used during labor
B. Plan for postpartum care on the maternity floor
C. Allow the parents to decide when to deliver
D. Immediately remove the infant from the room
after delivery
E. Avoid requesting an autopsy and stillbirth
evaluation
33. A 22-year-old G1P0 woman presents at 42 weeks D. Prostaglandins applied locally are the most commonly-used cervical
gestation. Her cervix is long and closed. She does ripening agents. RU486 is not used for cervical ripening. Membrane stripping
not report contractions and states there is good (digital separation of chorioamnion from lower uterine segment) and artificial
fetal movement. You discuss the benefits of rupture of membranes cannot be performed in a patient with a closed cervix.
induction at this time versus waiting until she goes The American College of Obstetricians and Gynecologists (ACOG)
into labor spontaneously. She agrees to proceed recommendations for the management of postterm pregnancy includes
with an induction. Which of the following is the patient records fetal kick counts and fetal surveillance using one of the
best next step in the management of this patient? following: NST, CST, biophysical profile and delivery for nonreassuring testing.
If the patient has a favorable cervix, induce at 42 weeks and, if the cervix is
A. Artificial rupture of membranes unfavorable, use cervical ripening agents.
B. Membrane stripping
C. Oxytocin infusion
D. Prostaglandin E1 tablet
E. RU486 (progesterone antagonist)
34. A 22-year-old G1P0 woman presents to the emergency department C. This patient is actively bleeding and is anemic. She,
at eight weeks gestation experiencing heavy vaginal bleeding. On therefore, requires immediate surgical treatment consisting
physical exam: blood pressure 94/60; pulse 108; respirations 20; and of dilation and suction curettage. Although clinicians
temperature 98.6F (37.0C). Pelvic examination demonstrates brisk increasingly utilize both expectant management and
bleeding through a dilated cervical os. The patient's hemoglobin is 7 various drug regimens to treat spontaneous abortion, a
g/dL (hematocrit 21%). Which of the following is the most appropriate prerequisite for either is that the patient is hemodynamically
next step in the management of this patient? stable and reliable for follow-up care. She is not
hemodynamically stable. Endometrial ablation will not work
A. Administration of intravaginal misoprostol in this case, as the products of conception need to be
B. Administration of oral misoprostol evacuated to control the bleeding.
C. Dilation and suction curettage
D. Endometrial ablation
E. Expectant care to permit spontaneous abortion
35. A 22-year-old G1P1 woman delivered her first baby five days ago C. Septic thrombophlebitis involves thrombosis of the
after a prolonged labor and subsequent Cesarean section for arrest venous system of the pelvis. Diagnosis is often one of
of cervical dilation at 7 cm. Fever was noted on postoperative day exclusion of other causes, but sometimes a CT scan will
two and, despite broad spectrum antibiotics, she continues to have reveal thrombosed veins. Treatment requires addition of
temperature spikes above 101.3 F (38.5 C). She is eating a normal anticoagulation to antibiotics and resolution of fevers is
diet and ambulating normally. On physical examination, her breasts rapid. Anticoagulation treatment is short-term. Classic
have no erythema and nipples are intact. Her abdomen is soft, clinical findings for endometritis include fever and maternal
uterine fundus is firm and nontender, and her incision is healing tachycardia, uterine tenderness and no other localizing
without induration or erythema. She has normal lochia and her signs of infection. The clinical manifestations of cystitis
urinalysis is normal. Pelvic examination reveals a firm nontender include lower abdominal pain, frequency, urgency and
uterus and no adnexal masses or tenderness. Which of the following dysuria. The clinical findings in patients with mastitis include
is the most likely cause of her fevers? fever, tenderness, induration and erythema of the affected
breast.
A. Mastitis
B. Endometritis
C. Ovarian abscess
D. Cystitis
E. Septic pelvic thrombophlebitis
36. A 22-year-old G1P1 woman delivered her first baby five days ago E. Septic thrombophlebitis involves thrombosis of the
after a prolonged labor and subsequent Cesarean section for arrest venous system of the pelvis. Diagnosis is often one of
of cervical dilation at 7 cm. Fever was noted on postoperative day exclusion of other causes, but sometimes a CT scan will
two and, despite intravenous broad spectrum antibiotics, she reveal thrombosed veins. Treatment requires addition of
continues to have temperature spikes above 101.3 F (38.5 C). She is anticoagulation to antibiotics and resolution of fevers is
eating a normal diet and ambulating normally. On physical generally rapid. Anticoagulation treatment is short-term.
examination, her breasts have no erythema and nipples are intact. The addition of oral antibiotics has no extra benefit on a
Her abdomen is soft, uterine fundus is firm and nontender, and her patient who is already on broad spectrum IV antibiotics.
incision is healing without induration or erythema. She has normal She has no evidence of fungal or viral infections, so
lochia and her urinalysis is normal. Pelvic examination reveals a firm therapy for these is not indicated. There is also no
nontender uterus and no adnexal masses or tenderness. Which of the indication she needs surgery.
following treatments is indicated for this patient?
A. Seizures
B. Paralysis
C. Respiratory depression
D. Pulmonary edema
E. Cardiac arrest
39. A 22-year-old G2P1 woman has a D. The diagnosis of postterm pregnancy is based on the establishment of an accurate
history of a previous postterm gestational age. In a patient with irregular menses, it is important to obtain an ultrasound
pregnancy. She delivered a 3500 g prior to 20 weeks to accurately date the pregnancy. It is reasonable to allow a patient with
healthy male infant at 42- weeks reassuring fetal surveillance to go past 41 weeks gestation if her gestational age is
gestation via a Cesarean section accurately known. However, because of a prior Cesarean birth, consideration should be
secondary to fetal distress. She is given to delivery before 41 weeks. Approximately 50% of patients with a history of a
currently 15 weeks pregnant, based on postterm pregnancy will experience prolonged pregnancy with the next gestation. There is
an irregular last menstrual period. currently no indication to begin antenatal testing at 40 weeks in this pregnancy.
What is the most appropriate
management at this time?
A. Fatigue
B. Sleep disturbance
C. Headache
D. Irritability
E. Agitation
44. A 23-year-old G1P0 woman at 40 weeks gestation presents to labor E. The patient has an arrest of dilatation in the active
and delivery with contractions. At 10:00 am, her cervical exam is 2 phase of labor. She is only having contractions every 5-6
centimeters dilated, 70% effaced and the vertex at 0 station. Clinical minutes, so it is reasonable to start oxytocin to increase
pelvimetry reveals an adequate pelvis and membranes are intact. The the frequency and strength of this patient's contractions.
fetus is in a cephalic presentation and EFW is 3500 gms. Contractions If the patient does not have cervical change once she is
are occurring every 3-4 minutes, based on the external monitor. Her having more frequent contractions on oxytocin, it would
labor slowly progresses and, at 1:00 pm, the patient has spontaneous be reasonable to place an IUPC (intrauterine pressure
rupture of membranes. Fetal surveillance remains Category I. Her catheter) to assess the strength of the contractions. It is
cervical exam is 5 centimeters dilated, 100% effaced, and 0 station. At not yet necessary to perform a Cesarean delivery. Further
4:00 pm, the patient's cervical exam is unchanged. Contractions are observation and having the patient ambulate do not
occurring every 5-6 minutes. Which of the following is the most facilitate delivery. A biophysical profile is not indicated in
appropriate next step in the management of this patient? this situation.
A. Endomyometritis
B. Septic pelvic thrombophlebitis
C. Mastitis
D. Breast engorgement
E. Vaginitis
48. A 23-year-old G1P1 woman delivered vaginally at 42-weeks D. Acute cystitis is a common complication after vaginal delivery and
gestation after a prolonged induction of labor. She had an the risk increases with the use of an indwelling catheter. The most
epidural with an indwelling catheter for 36 hours and three common cause of acute cystitis infection is gram-negative bacteria.
IV sites for her intravenous medications. She now complains The major pathogens are E. coli (75%), P. mirabilis (8%), K. pneumoniae
of lower abdominal pain, frequency and dysuria. Her vital (20%), S. faecalis (<5%), and S. agalactiae.
signs are: temperature 98.6 F (37 C); pulse 70; blood
pressure 100/60; and respirations 12. On examination, her
lungs are clear, cardiac exam is normal, abdomen is soft,
uterine fundus is firm and nontender, and she has mild
suprapubic tenderness. Which of the following organisms is
most likely causing her discomfort?
A. Group A streptococcus
B. Proteus mirabilis
C. Klebsiella pneumoniae
D. Escherichia coli
E. Group B Streptococcus
49. A 23-year-old G1P1 woman diagnosed with postpartum E. This patient offered thoughts of suicidal ideation, thus inpatient
depression at three months after a spontaneous vaginal management is the most appropriate choice. While behavioral
delivery has suicidal ideation and is desperate for help. psychotherapy is necessary to establish long-term strategies for
Which of the following is the most appropriate next step in coping skills, newer regimens for postpartum depression include the
the treatment of this patient? use of SSRI medication. SSRI medications have been shown to hasten
recovery to a fully functioning state. Antipsychotic medication is not
A. Behavioral psychotherapy indicated without an established diagnosis. Electroconvulsive therapy
B. Anti-depressant medication may be indicated for patients who don't respond to standard
C. Anti-psychotic medication depression treatments.
D. Electroconvulsive therapy (ECT)
E. Inpatient psychiatric admission
50. A 23-year-old G1P1 woman is five days post- D. Mixed bacteria originating from the skin, uterus and vagina cause wound infections
operative from a Cesarean section for arrest after a Cesarean section. Prior to establishing a diagnosis of surgical site infection,
of labor at 7 cm. She now complains of evaluation requires opening the wound, checking for fascial dehiscence, drainage
minimal abdominal pain and drainage from and assessment of the fluid. Packing the wound until it has healed from the base of
the right side of the incision. Lochia is the wound facilitates the healing process. Broad spectrum antibiotics are indicated if
normal and she has no urinary complaints. you suspect cellulitis or abscess.
Her vital signs are normal and she is
afebrile. On physical exam, her lung and
cardiac examinations are normal. Her
abdomen and uterine fundus are nontender.
Her Pfannenstiel incision has tenderness
extending 3 cm from the incision and there
is serous, bloody drainage coming from the
right side. What is the next best step in the
management of this patient?
A. Mild preeclampsia
B. Hepatitis
C. HELLP syndrome
D. Cholecystitis
E. Acute fatty liver
52. A 23-year-old G2P1 woman at 36 weeks gestation presents C. This patient is near term with a third episode of active bleeding
with her third episode of heavy vaginal bleeding. She has from a placenta previa. The appropriate next step would be to move
normal prenatal labs and a known placenta previa. She towards delivery via Cesarean section. The patient is not
denies uterine contractions or abdominal pain and reports experiencing contractions, so tocolysis is not necessary and would
good fetal movement. Her vital signs are: blood pressure not be used with heavy vaginal bleeding. Catastrophic bleeding
100/60; pulse 110; and she is afebrile. Her abdomen and could occur due to disruption of blood vessels as the cervix dilates
uterus are non-tender. Fundal height measures 35 if a vaginal delivery is pursued, and induction of labor would
centimeters and fetal heart tones reveal a baseline of 140 therefore be contraindicated. An amniocentesis is not indicated in
and are reassuring. Pelvic ultrasound confirms a placenta this situation. Although the patient is not yet at term, delivery is
previa and the fetus is in the cephalic presentation. appropriate due to the third episode of heaving bleeding at near
Hematocrit is 29%. Which of the following is the most term. Administering steroids is not appropriate at this gestational
appropriate next step in the management of this patient? age.
A. Tocolysis
B. Induction of labor
C. Cesarean delivery
D. Amniocentesis
E. Administer steroids
53. A 24-year-old G1P0 at 32 weeks gestation presents with C. Thirty (30) cc of fetal blood is neutralized by the 300 micrograms
vaginal bleeding most likely caused by placental abruption. dose of RhoGAM. This is equivalent to 15 cc of fetal red blood cells.
She receives a standard dose of 300 micrograms of At 28-weeks gestation, 300 micrograms of Rh-immune globulin is
RhoGAM. What amount of fetal blood is neutralized by this routinely administered after testing for sensitization with an indirect
dose? Coombs' test. Administration is given following amniocentesis at any
gestational age.
A. 10 cc
B. 20 cc
C. 30 cc
D. 40 cc
E. 50 cc
54. A 24-year-old G1P0 woman at 12 weeks gestation presents A. The body mass index (BMI) is equal to a person's weight in kg
for prenatal care. She is 5 feet 4 inches tall and weighs 220 divided by their height in meters squared. The National Heart, Lung,
pounds (BMI: 37.8 kg/m2). She wants to know if there is an and Blood Institute identify a normal BMI as 18.5 to 24.9 kg/m2;
increased risk on her pregnancy because of her size. Which overweight as a BMI of 25 to 29.9 kg/m2; and obesity as a BMI of 30
of the following is the most common complication in this kg/m2 or greater. Obesity is further categorized as class I (BMI: 30
patient? to 34.9 kg/m2), class II (BMI: 35 to 39.9 kg/m2), and class III (BMI: >
or = 40 kg/m2). Increased maternal morbidity results from obesity
A. Hypertension and includes chronic hypertension, gestational diabetes,
B. Preterm labor preeclampsia, fetal macrosomia, as well as higher rates of Cesarean
C. Post-term pregnancy delivery and postpartum complications. This patient's BMI is
D. Small for gestational age approximately 38 so she is a class II and has over a 7-fold increase
E. Shoulder dystocia risk for preeclampsia and a 3-fold risk for hypertension.
55. A 24-year-old G1P0 woman at 22 weeks gestation with A. Lupus is notoriously variable in its presentation, course, and
systemic lupus erythematosus (SLE) presents complaining of outcome. Clinical manifestations include malaise, fever, arthritis, rash,
malaise, joint aches, and fever. Physical examination reveals pleuro-pericarditis, photosensitivity, anemia, and cognitive
the following: pulse 88; temperature 98.6F (37.0C); dysfunction. A significant number of patients have renal involvement.
respiratory rate 22; and BP 150/110 (baseline is 100/70). There is no cure and complete remissions are rare. Mild disease may
Laboratory analysis reveals 1 + proteinuria, AST 35, and ALT be disabling because of pain and fatigue. Nonsteroidal anti-
28. Which of the following is the most appropriate initial inflammatory drugs are used to treat arthralgia and serositis. Severe
therapy for the treatment of this patient? disease is best treated with corticosteroids. Hydroxychloroquine is
used to help control skin manifestations and may be associated with
A. Steroids lupus flares if discontinued. Azathiopine and cyclophosphamide are
B. Nonsteroidal anti-inflammatory drugs (NSAIDs) not indicated in this patient.
C. Azathioprine
D. Cyclophosphamide
E. Magnesium sulfate
56. A 24-year-old G1P0 woman at 32 weeks gestation presents A. Maternal signs of chorioamnionitis or other evidence of intra-
with leaking watery fluid from the vagina. On evaluation, amniotic infection are indications for delivery. This patient has ruptured
preterm premature rupture of membranes is confirmed. membranes and a tender fundus, which indicate chorioamnionitis.
She has occasional Braxton Hicks contractions associated Labor at 32 weeks would be allowed to progress and prolonged non-
with fetal heart rate accelerations. She does not have reassuring fetal testing would prompt delivery. There are no criteria for
vaginal bleeding and vaginal fluid phosphatidylglycerol is amniotic fluid index or degree of oligohydramnios as an indication for
absent. Her blood pressure is 110/70; pulse 90; delivery. Most authors agree that the achievement of fetal lung
temperature 98.6F (37.0C). Fundal height is 30 cm and maturity (i.e. positive phosphatidylglycerol or 34 weeks gestational
her fundus is tender. Amniotic fluid index (AFI) is 4. Which age) is the threshold at which the risk of morbidity and mortality of
of the following findings is an indication for delivery in this maintaining the pregnancy in utero outweighs the benefits of
patient? prolonging the pregnancy.
A. Endometrial cultures
B. Chest X-ray
C. Treatment with intravenous broad spectrum antibiotics
D. Pelvic ultrasound
E. Culture of the incision
58. A 24-year-old G1P1 woman just delivered a healthy infant B. A patient's history of a psychiatric illness is a risk factor for the
at term. She has a history of a psychiatric disorder and was development of a postpartum depression. Patients with a prior history
treated for depression while in college. Which of the of depression, either situational or spontaneous, are at very high risk
following is she at most increased risk for in the for postpartum depression. In fact, one-third of patients with a
postpartum period? postpartum psychiatric problem report a prior history. These patients
need careful follow up after delivery, which should include an early
A. Postpartum blues appointment for a postpartum visit. Questions at this time should be
B. Postpartum depression directed to her moods and thoughts.
C. Postpartum psychosis
D. Postpartum anxiety
E. She is not at increased risk for a psychiatric disorder
59. A 24-year-old G2P1 woman at 18 weeks gestation C. Asthma generally worsens in 40% of pregnant patients. One of the indications
with a history of asthma presents to the office for moving to the next line of treatment includes the need to use beta agonists
with worsening symptoms, needing to use her more than twice a week. The appropriate choice for her treatment would be
inhaler more frequently. The symptoms began inhaled corticosteroids or cromolyn sodium. Theophylline would be used in
with the pregnancy and have gradually more refractory patients. Subcutaneous terbutaline and systemic corticosteroids
increased. She is using her albuterol inhaler as would be used in acute cases. Zafirlukast, a leukotriene receptor antagonist, is
needed, recently three times a day. She denies not effective for acute disease. The safety of zafirlukast in pregnancy is not well
any illness or fever. She has had asthma since she established because there is little experience with their use in pregnancy.
was a child. On exam, the patient appears Antibiotic treatment is only used when a pulmonary infection is diagnosed.
comfortable. Her temperature is 100.2F (37.9C)
and respiratory rate is 18. Auscultation of the
lungs shows good air movement with mild
scattered end expiratory wheezes. There are no
rales or bronchial breath sounds. Which of the
following is the most appropriate next step in the
management of this patient?
A. Oral theophylline
B. Subcutaneous terbutaline
C. Inhaled corticosteroids
D. Oral zafirlukast (leukotriene inhibitor)
E. Antibiotic treatment
60. A 24-year-old G2P1 woman at 30 weeks D. On rare occasion, an Rh-negative woman will subsequently be sensitized,
gestation is sensitized to the D antigen. She is despite prophylaxis. The protection afforded by a standard RhoGAM
Rh-negative and received RhoGAM after her first administration is dose-dependent. One dose will prevent Rh sensitization to an
delivery one year ago. Which of the following exposure of as much as 30 cc of Rh-positive red blood cells. With greater
statements best explains these findings? exposure, there is only partial protection and Rh sensitization may occur as a
result of failure to diagnose massive transplacental hemorrhage. Alternatively,
A. The patient initiated her prenatal care late an Rh-negative woman may be sensitized in the latter part of pregnancy or
during the present pregnancy soon after delivery before the post-delivery prophylaxis dose is given.
B. The patient was sensitized during the previous Inadvertent maternal transfusion of Rh-positive blood may result in Rh
pregnancy by receiving the RhoGAM sensitization to the D or another red blood cell antigen. Patients may become
C. Current pregnancy is too close to the first sensitized if they do not receive RhoGAM following an episode of antenatal
pregnancy bleeding or after an invasive procedure, such as amniocentesis or chorionic
D. The amount of fetal maternal hemorrhage was villus sampling. In addition, RhoGAM only confers protection against the D
more than previously estimated antigen. Therefore, despite administration of RhoGAM to Rh-negative patients,
E. The cause is most likely idiopathic in this case they may still become sensitized to other red blood cell antigens. Pregnancy
spacing does not affect the presence of the antibody.
61. A 24-year-old G2P1 woman at 42 weeks C. Amnioinfusion is a procedure where normal saline is infused into the
gestation presents in early labor. At amniotomy, intrauterine cavity. Amnioinfusionremains a reasonable approach in the
there is thick meconium and variable treatment of repetitive variable decelerations, regardless of amniotic fluid
decelerations are noted. An amnioinfusion is meconium status. Meconium staining of the amniotic fluid is three to four times
started. Which of the following is most likely to more common in the postterm pregnancy. This is likely due to two reasons: 1)
decrease in this patient? greater length of time in utero allows for activation of a more mature vagal
system; and 2) fetal hypoxia. Routine prophylactic amnioinfusion for thick
A. Admission to the neonatal intensive care unit meconium does not appear to decrease the incidence of meconium aspiration
B. Post maturity syndrome syndrome or have an impact on neonatal outcomes. Based on current literature,
C. Repetitive variable decelerations routine prophylactic amnioinfusion for meconium-stained amniotic fluid is not
D. Risk for Cesarean section recommended.
E. Meconium presence below the vocal cords
62. A 24-year-old G2P1 woman has a fetus that is C. Values in Zone 3 of the Liley curve indicate the presence of severe hemolytic
affected by Rh disease. At 30 weeks gestation, disease, with hydrops and fetal death likely within 7-10 days, thus demanding
the delta OD450 (optical density deviation at 450 immediate delivery or fetal transfusion. At 30 weeks gestation, the fetus would
nm) results plot on the Liley curve in Zone 3, benefit from more time in utero. An attempt should be made to correct the
indicating severe hemolytic disease. Which of the underlying anemia. Intravascular transfusion into the umbilical vein is the
following is the most appropriate next step in the preferred method. Intraperitoneal transfusion is used when intravascular
management of this patient? transfusion is technically impossible. If fetal hydrops is present, the reversal of
the fetal anemia occurs much more slowly via intraperitoneal transfusion.
A. Immediate Cesarean delivery Percutaneous umbilical blood sampling should not be used as a first-line
B. Induction of labor method to evaluate fetal status. Maternal plasmapheresis is used in severe
C. Intrauterine intravascular fetal transfusion disease when intrauterine transfusions are not possible.
D. Umbilical blood sampling
E. Maternal plasmapheresis
63. A 24-year-old G2P1 woman is diagnosed with Rh E. In the presence of a severely erythroblastotic fetus, the amniotic fluid is
hemolytic disease at 24 weeks gestation. stained yellow. The yellow pigment is bilirubin, which can be quantified most
Measurement of which of the following in the accurately by spectrophotometric measurements of the optical density
amniotic fluid is best indicative of the severity of between 420 and 460nm, the wavelength absorbed by bilirubin. The deviation
the disease? from linearity of the optical density reading at 450nm is due to the presence of
heme pigment, an indicator of severe hemolysis. Amniotic fluid ferritin, an acute-
A. Hemoglobin phase reactant, is associated with spontaneous preterm delivery and not with
B. Iron Rh isoimmunization.
C. Anti-D antibody titer
D. Ferritin
E. Bilirubin
64. A 24-year-old G2P1 woman is undergoing a D. Correcting coagulation deficiencies requires replacing all necessary blood
Cesarean delivery for placental abruption. She components. Fresh frozen plasma contains fibrinogen, as well as clotting factors
presented to labor and delivery with severe V and VIII. Cryoprecipitate contains fibrinogen, factor VIII and von Willebrand's
abdominal pain and heavy vaginal bleeding. The factor. Neither of these preparations contains red blood cells or platelets, which
fetus was delivered uneventfully. The placenta must be given separately.
delivered with a significant clot attached to the
maternal surface. The patient continues to bleed
from the placental bed. Estimated blood loss is
1500 ml. The operative team decides to give her
fresh frozen plasma (FFP) to replace which of the
following components?
A. Platelets
B. Von Willebrand's factor
C. Red blood cells
D. Fibrinogen
E. Factor X
65. A 24-year-old G3P0 woman at 26 weeks gestation was brought to the hospital B. This is a patient in septic shock. The most
by paramedics. Her husband found her shivering and barely responsive. Two common cause of sepsis in pregnancy is acute
days prior, the patient noted that she was feeling sick, with a slight cough. She pyelonephritis. Given the absence of bleeding,
was having back pain at the time, but thought it was probably normal for the clinical picture is not suggestive of placental
pregnancy. Her pregnancy has been uncomplicated except for the recent abruption. Diabetic ketoacidosis is unusual in
diagnosis of gestational diabetes. On exam, vital signs are: temperature 100.2F gestational diabetic patients. Chorioamnionitis
(37.9C); pulse 160; and blood pressure 68/32; respiratory rate 32. Oxygen and pneumonia may both lead to sepsis, but are
saturation is 82% on room air. There is no apparent fundal tenderness, although not suggested by the clinical picture.
the patient exhibits pain with percussion of the right back. Fetal heart tones are
not audible. There is no evidence of vaginal bleeding. Extremities are cool to
touch. White blood cell count 24,000; hemoglobin 9.5; hematocrit 27%. Urine
microscopic analysis shows many white blood cells. What is the most likely
etiology for this patient's disease?
A. Abruptio placentae
B. Pyelonephritis
C. Diabetic ketoacidosis
D. Chorioamnionitis
E. Pneumonia
66. A 24-year-old G4P0 woman presents to your office at seven weeks gestation B. Autosomal trisomy is the most common
after two days of bleeding and cramping. She thinks that she miscarried at abnormal karyotype encountered in spontaneous
home and brought in the tissue for pathologic evaluation. What is the abortuses, accounting for approximately 40-50%
karyotype most likely to be found on chromosomal analysis? of cases. The most common chromosomal
aneuploidy noted in abortuses is Trisomy 16.
A. Turner Syndrome (45, X) Triploidy accounts for approximately 15%, and
B. Autosomal Trisomy tetraploidy for 5% of cases. Monosomy X (45X, 0)
C. Monoploidy is seen in 15-25% of losses.
D. Triploidy
E. Tetraploidy
67. A 24-year-old Rh-negative G1P1 woman just delivered a healthy term infant A. The risk of isoimmunization is 2% antepartum,
who is Rh-positive. You recommend RhoGAM administration but she declines 7% after full term delivery, and 7% with
because she does not desire any blood products. What is her approximate risk subsequent pregnancy so less than 20% total.
of isoimmunization if she does not receive the RhoGAM? While 75% of all gravidas have evidence of
transplacental hemorrhage during pregnancy or
A. Less than 20% immediately after delivery, 60% of these patients
B. 40% have <0.1 cc of fetal blood in the maternal
C. 60% circulation, which is enough to sensitize a patient.
D. 80% The incidence and size of transplacental
E. 100% hemorrhage increases as pregnancy advances.
During the second month of gestation, 5-15% of
women will have evidence of feto-maternal
hemorrhage. By the third trimester, this number
increases to 45% of patients.
68. A 24-year-old Rh-negative G2P1 woman at 18 E. Noninvasive diagnosis of fetal anemia can be performed with Doppler
weeks gestation is positive for anti-D antibodies. ultrasonography. The use of middle cerebral artery peak systolic velocity in the
In discussing the risks of Rh sensitization with her, management of fetuses at risk for anemia because of red cell alloimmunization
you tell her that her fetus may be at increased has emerged as the best test for the noninvasive diagnosis of fetal anemia. All
risk of significant perinatal disease including fetal the other listed tests are for assessment of fetal well-being and non-specific to
anemia. Which of the following non-invasive tests detect fetal anemia. Amniocentesis and cordocentesis have been used for many
can detect severe fetal anemia? years to diagnose fetal anemia due to red cell alloimmunization. These
techniques, however, are invasive and many complications are associated with
A. Umbilical artery systolic-diastolic ratio their use.
B. Biophysical profile
C. Amniotic fluid index
D. Umbilical artery blood flow
E. Middle cerebral artery peak systolic velocity
69. A 24-year-old Rh-negative G2P1 woman is found D. Fetal hydrops is easily diagnosed on ultrasound. It develops in the presence
at 10 weeks gestation to have anti-D antibodies. of decreased hepatic protein production. It is defined as a collection of fluid in
You follow her closely during this pregnancy and two or more body cavities, such as ascites, pericardial and/or pleural fluid and
order serial ultrasound examinations. Which of scalp edema. On occasion, when extramedullary hematopoiesis is extensive,
the following fetal ultrasound findings would be there will be evidence of hepatosplenomegaly. Placentomegaly (placental
most explained by the presence of Rh disease? edema) and polyhydramnios are also seen on ultrasound. Meconium, fetal
bladder obstruction, oligohydramnios and placenta previa do not fit the clinical
A. Meconium scenario.
B. Fetal bladder obstruction
C. Oligohydramnios
D. Pericardial effusion
E. Placenta previa
70. A 25-year-old G0 woman presents to her doctor C. Smoking increases the risk of several serious complications of pregnancy,
for preconception counseling. She is healthy including placental abruption, placenta previa, fetal growth restriction,
without significant medical problems. She takes preeclampsia and infection. Women who smoke should be counseled
no medications. She smokes one pack of vigorously to quit smoking prior to conception and to resist restarting after the
cigarettes per day since age 16 and drinks baby is born.
occasionally. She weighs 140 pounds and her vital
signs and examination are normal. The patient is
at increased risk of which of the following during
her pregnancy?
A. Immunologic abnormalities
B. Conceptus genetic anomalies
C. Maternal genetic anomalies
D. Structural/uterine anomalies
E. Uterine infections
72. A 25-year-old G1P0 woman at 29 weeks gestation presents C. Variable decelerations are a result of cord compression. With
to labor and delivery complaining of contractions every 3 cord compression, initially there is a short increase in fetal heart rate
minutes. On exam, her blood pressure is 120/70; heart rate is followed by an abrupt drop in heart rate. As the compression is
100; temperature is 100.7F (38.2C); and fetal heart tones are released, the fetal heart rate returns to baseline, frequently with a
in the 160's. The fetal heart rate tracing is showing deep brief, slight increase. Variable decelerations can occur at any point.
variable decelerations, but is otherwise is reassuring. Her This patient has PPROM and a frequent cause of cord compression
pelvic examination reveals gross rupture of membranes and can be lack of amniotic fluid. Chorioamnionitis is an infection of the
her cervix is dilated to 6 cm and ultrasound reveals the baby amniotic fluid and chorion that explains this patient's fever, but is not
is in the breech presentation. What of the following explains a cause of variable decelerations. Breech presentation, and
the variable decelerations? gestational age do not cause variable decelerations.
A. Chorioamnionitis
B. Labor
C. Premature Rupture of Membranes
D. Breech presentation
E. Gestational age
73. A 25-year-old G1 woman at 41 weeks gestation presents to C. Breech presentation occurs in approximately 3-4% of women in
labor and delivery with painful contractions every four labor overall, and occurs more frequently in preterm deliveries.
minutes. Her cervix is 5 cm dilated, 90% effaced. On cervical Frank breech is the most common type, occurring in 48-73% of
exam, you are able to feel a fetal body part but it is not the cases and the buttocks are the presenting part. Complete breech is
head. Which of the following is the most likely body part you found in approximately 5-12% of cases and incomplete breech
were palplating? (footling breech) occurs in approximately 12-38% of cases.
A. Foot
B. Hand
C. Buttocks
D. Back
E. Shoulder
74. A 25-year-old G1 woman at term presents in active labor. C. Continued monitoring of labor is appropriate if clinical evaluation
Her cervix rapidly changes from 7 centimeters to complete indicates that the fetus is not macrosomic or there is no obvious
dilation in 1 hour. She has been pushing for two hours. The fetopelvic disproportion. If either were the case, then a Cesarean
fetal station has changed from -1 to +1. Fetal heart tracing is delivery would be indicated. At this time, there is no fetal or maternal
Category I. The patient is feeling strong contractions every indication to perform a forceps delivery because the station is +1.
three minutes. Which of the following is the most Augmentation would be indicated if the contractions were
appropriate next step in the management of this patient? inadequate in intensity or frequency. An ultrasound at this stage of
labor is inaccurate and one relies on clinical estimates of weight.
A. Cesarean delivery
B. Forceps delivery
C. Continued monitoring of labor
D. Augmentation with oxytocin
E. Ultrasound for estimated fetal weight
75. A 25-year-old G2P1 woman at 20 weeks gestation A. Preterm premature rupture of the membranes that occurs before viability is
is diagnosed with preterm premature rupture of associated with significant risk of poor outcome. Neonatal survival when
the membranes. She denies labor. She takes rupture occurs between 20 and 23 weeks is approximately 25%. Complications
prenatal vitamins and iron. She denies substance that may be found in the developing fetus include structural abnormalities that
abuse, smoking or alcohol use. Her prior are primarily deformations (abnormalities that occur due to an insult after a
pregnancy was delivered vaginally at 36 weeks structure has already formed) rather than malformations (abnormal
after preterm rupture of membranes. Her blood development of the structure itself). Pulmonary hypoplasia is seen when
pressure is 110/70; pulse 84; temperature 98.6F rupture of membranes occurs before 25 weeks gestation because the lack of
(37.0C). Her amniotic fluid index is 2. The patient's amniotic fluid interferes with the normal intrauterine breathing process. The
fetus is greatest risk for which of the following? result is failure of normal development and growth of the respiratory tree.
A. Pulmonary hypoplasia
B. Cardiac anamolies
C. Urinary tract anamolies
D. Microcephaly
E. Compression fractures
76. A 25-year-old G2P1 woman at eight weeks C. Environmental factors, such as smoking, alcohol and radiation are causes of
gestation is diagnosed with a spontaneous spontaneous abortion. Although the risk increases with infections, such as
abortion. Her husband is 40 years old. The patient's listeria, mycoplasma, ureaplasma, toxoplasmosis and syphilis, advancing
past medical history is noncontributory. She gets maternal or paternal age, advancing parity and some mullerian anomalies, the
some exercise regularly and smokes two packs of clinical scenario does not support these as possible causes. An isolated
cigarettes a day. Three years ago, she had a full- history of preeclampsia confers no increase in risk of spontaneous abortion.
term delivery that was complicated by mild
preeclampsia. Which of the following factors is
most likely the cause of this spontaneous
abortion?
A. Infection
B. Advanced paternal age
C. Environmental factors
D. Uterine anomaly (i.e. unicornuate uterus)
E. History of preeclampsia
77. A 25-year-old G2P1 woman presents at 26 weeks A. ! High levels of magnesium sulfate may cause respiratory depression (12-15
gestation with preterm labor. She is currently mg/dl) or cardiac depression (>15 mg/dl). Prior to developing respiratory
receiving tocolytic therapy with magnesium sulfate. depression the patient should have diminished or absent deep tendon reflexes
The patient's nurse is concerned the patient may (areflexia). Magnesium sulfate does not cause hypertension.
have magnesium sulfate toxicity. The patient is
alert and has no complaints. Her contractions have
stopped and her vital signs are stable. Which of
the following findings associated with magnesium
sulfate treatment would this patient experience
before she develops respiratory depression?
A. Areflexia
B. Hyperreflexia
C. Tachycardia
D. Hypertension
E. Oligouria
78. A 25-year-old G2P1 woman states her C. Alpha fetoprotein (AFP) levels in twin gestations are elevated and should be
gestational age by known LMP is 16 weeks, 3 roughly twice that seen in singleton pregnancies. An additional clue to a possible
days. She reports no complaints and is not yet diagnosis of twin gestation is the fundal height exceeding gestational age in
feeling fetal movement. Her fundal height is 22 weeks. Other causes of elevated maternal serum AFP include neural tube defects,
cm. The MSAFP (maternal serum alpha pilonidal cysts, cystic hygroma, sacrococcygeal teratoma, fetal abdominal wall
fetoprotein) result is elevated. Which of the defects, and fetal death. Polyhydramnios is not by itself associated with abnormal
following is the most likely cause for the MSAFP levels.
abnormal MSAFP result?
A. Fetal trisomy
B. Polyhydramnios
C. Twin gestation
D. Fetal abdominal wall defect
E. Fetal neural tube defects
79. A 26-year-old G1P0 woman with last menstrual B. A maternal blood type should be checked on all women with vaginal bleeding
period 13 weeks ago presents to your office for during pregnancy, unless it was documented earlier in the pregnancy. If the
her first prenatal visit. She reports vaginal patient's blood type is Rh-negative, RhoGAM would be indicated to prevent Rh
spotting for the last two days. You perform an sensitization. Serial quantitative Beta-hCGs can be useful in confirming an
ultrasound that shows an intrauterine ongoing pregnancy before fetal heart rate activity can be noted, but in this case
pregnancy consistent with 11 weeks gestation there is a non-viable intrauterine pregnancy. The patient is unlikely to have had
with no cardiac activity. She denies cramping or significant blood loss making a blood or platelet count unlikely to be necessary at
abdominal pain. What is the most important this time. Although progesterone levels can be useful in determining if a
laboratory test to check for this patient? pregnancy is failing, the diagnosis is already clear in this case.
A. Quantitative Beta-hCG
B. Maternal blood type
C. Hemoglobin and hematocrit
D. Platelet count
E. Progesterone
80. A 26-year-old G2P0 woman presents for A. Neither controlled trials nor surveillance data support the contention that a
counseling following manual vacuum aspiration single, prior first trimester surgical abortion increases the risk of subsequent first
of an eight-week missed abortion. The patient trimester pregnancy loss. Indeed, first trimester surgical abortion confers no
asks whether an uncomplicated first trimester subsequent obstetric disadvantage, particularly when compared with an
pregnancy termination three years ago might appropriate control population. The clinician should reassure this patient that first
have predisposed her to the subsequent trimester spontaneous abortion is a common occurrence and that she has not
spontaneous abortion. What are the patient's caused this missed abortion.
risks associated with the prior surgical abortion
in the first trimester?
A. Nifedipine
B. Terbutaline
C. Magnesium sulfate
D. Indomethacin
E. Ritodrine
82. A 27-year-old G1P0 woman at 14 weeks gestation A. This patient has classic depression. The most commonly used antidepressants
presents with a two-month history of insomnia, are the selective serotonin reuptake inhibitors (SSRIs). One SSRI, paroxetine
feeling depressed, and unintentional weight loss. (Paxil) has been changed to a category D drug because of the increased risk of
Symptoms began after the unexpected death of fetal cardiac malformations and persistent pulmonary hypertension. Other SSRI
her father. She is not excited about this compounds, fluoxetine, sertraline, and citalopram have not been reported to
pregnancy and reports no suicidal ideation. cause early pregnancy loss or birth defects in animals or in humans. Because
Physical examination reveals a woman of stated these agents have few side effects compared with other antidepressants, they
age with a flat affect. Which of the following are a good choice for pregnant women. Bupropion is not an MAO inhibitor, nor
therapies is contraindicated in this patient? is it an SSRI and a report by the Bupropion Pregnancy Registry reports no
unusual effects in 90 exposed pregnancies.
A. Paroxetine (Paxil)
B. Sertraline (Zoloft)
C. Fluoxetine (Prozac)
D. Citalopram (Celexa)
E. Bupropion (Wellbutrin)
83. A 27-year-old G1P0 woman at 32 weeks D. This woman presents with classic symptoms and findings for pneumonia. The
gestation presents complaining of cough, fever, typical symptoms include cough, dyspnea, sputum production, and pleuritic
chest pain, and dyspnea. Vital signs are pulse chest pain. Mild upper respiratory symptoms and malaise usually precede these
108; temperature 100.5 F (38.0 C); respiratory symptoms, and mild leukocytosis is usually present. Chest radiography is
rate 22 per minute. Physical examination reveals essential for diagnosis, although radiographic appearance does not accurately
right lower lobe bronchial breath sounds. Which predict the etiology of the pneumonia. Pulmonary function tests, blood and
of the following tests would be most appropriate sputum cultures, serological testing, cold agglutinin identification, and tests for
for making a diagnosis for this patient? bacterial antigens are not recommended in uncomplicated pneumonia.
A. Blood cultures
B. Sputum culture
C. Lower extremity dopplers
D. Chest x-ray
E. Pulmonary function tests
84. A 27-year-old G1P0 woman at 34 weeks A. This patient has met criteria for the diagnosis of mild preeclampsia based on her
gestation presents with increased persistent elevation of blood pressure and 24-hour urine results. The amount of protein
swelling in her face and hands over the excreted in the urine varies throughout the day, therefore a sample is collected over a
last two days. Blood pressure is 155/99. A 24-hour time period. Twenty-four hour urine protein values greater that 300 mg are
24-hour urine sample for protein is 440 required for the diagnosis of mild preeclampsia. Values greater than 5000 mg (or 5 g) are
mg/dL. BMI is 27. Repeat blood pressure required for the diagnosis of severe preeclampsia (assuming no other defining criteria
two days later is 150/92. Which of the are present such as SBP >160 or DBP >110). This patient has not had a seizure which is the
following is the most likely diagnosis in hallmark of eclampsia syndrome.
this patient?
A. Preeclampsia
B. Preeclampsia with severe features
C. Eclampsia Syndrome
D. Gestational hypertension
E. Chronic hypertension
85. A 27-year-old G1P0 woman presents to A. Uncontrolled glucose is associated with adverse fetal outcome. A patient with type 1
labor and delivery and is found to have diabetes is at risk for many pregnancy complications, including fetal death and fetal
a fetal demise at 34 weeks gestation. macrosomia, although fetal growth restriction may also occur. Diabetics also have
She did not have access to prenatal care increased risk for polyhydramnios, congenital malformations (cardiovascular, neural tube
during the pregnancy. Her vital signs are defects, and caudal regression syndrome), preterm birth, and hypertensive
normal and she is not in labor. Her complications. The anemia most often seen in pregnancy is mild and would not be the
uterus is non-tender and she does not most likely cause. It is unlikely that she has an abruption causing the anemia, but this
have any vaginal bleeding or ruptured should be considered. Hypothyroidism is usually associated with menstrual irregularities
membranes on exam. Which untreated and infertility, and is a less likely cause. Rh sensitization is unlikely since this is her first
condition is the most likely cause? pregnancy and she did not have any bleeding or procedures during the pregnancy.
A. Diabetes
B. Anemia
C. Hypothyroidism
D. Herpes
E. Rh-isoimmunization
86. A 27-year-old G1P1 woman with no A. Most depressed patients who are suicidal are relieved to be asked about it. Although
significant prior medical history reports all the items listed are components of a complete history, the most important topic is
three months of low energy, lack of assessment of suicide risk.
enjoyment with her daily activities, early
morning awakening, and trouble
concentrating. What is the next best step
in the assessment of this patient?
A. Risk of suicide
B. Willingness to accept medical
treatment
C. Family history of mental illness
D. Good support system
E. Current medication profile
87. A 27-year-old G1 woman at 36 weeks gestation is C. This patient has respiratory depression likely secondary to magnesium
undergoing an induction of labor for preeclampsia toxicity. In addition to discontinuing the magnesium sulfate, she needs a
with severe features. She complains of a headache, dose of calcium gluconate to restore her respiratory function. The classic
right upper quadrant pain and seeing spots. signs of magnesium toxicity include muscle weakness and loss of deep
Admission vital signs are: blood pressure 180/120, tendon reflexes, nausea, and respiratory depression. If magnesium is given
respiratory rate 20, pulse 92. In addition to 10 hours of in high doses, cardiac arrest is possible. Altering the oxytocin drip and a
oxytocin, she is receiving intravenous magnesium Cesarean delivery are not indicated at this time.
sulfate 2 g /hour. During the past two hours her urine
output has decreased to 15 mL per hour (down from
40 mL/h) and her respiratory rate is now 10. What is
the next best step in the management of this patient?
A. 50-55 mmHg
B. 60-65 mmHg
C. 70-75 mmHg
D. 80-85 mmHg
E. 90-95 mmHg
91. A 27-year-old G2P1 woman presents to the emergency D. This patient has the classic signs and symptoms of a uterine
department with increasing lower abdominal pain, nausea, perforation. Hematometra can develop after an abortion, but the
scant bleeding, and fever. She is two days postop from a patient would complain of cyclic midline abdominal cramping pain.
suction dilatation and curettage for an incomplete abortion. Retained products of conception would cause profuse vaginal
Vital signs: blood pressure 120/80, pulse 104, respiratory bleeding and if not removed may lead to a septic abortion.
rate 20, and temperature 100.4F (38.0C). Physical Complications that may occur secondary to suction dilatation and
examination reveals rebound tenderness and abdominal curettage include anesthesia risk, bowel and bladder injury, cervical
guarding, uterus soft and slightly tender. Which of the lacerations, and uterine perforations. If the patient had a cervical
following is most likely in this patient? laceration she would have more vaginal bleeding than scant.
A. Presence of leukocytes
B. Low Interleukin-6
C. Amniotic glucose less than 20 mg/dl
D. Elevated level of bilirubin
E. Lecithin/sphingomyelin (L/S) ratio <2
97. A 28-year-old G2P1 woman presents at 20 weeks gestation B. This patient was sensitized during her first pregnancy that was
for a routine prenatal care visit. This pregnancy has been complicated by abruption and required Cesarean delivery.
complicated by scant vaginal bleeding at seven weeks and Transplacental hemorrhage of fetal Rh-positive red blood cells into
an abnormal maternal serum alpha fetoprotein (MSAFP) the circulation of the Rh-negative mother may occur following a
with increased risk for Down syndrome, but normal number of obstetric procedures and complications, such as
amniocentesis: 46, XX. Her previous obstetric history is amniocentesis, chorionic villus sampling, spontaneous/threatened
significant for a Cesarean delivery at 34 weeks due to abortion, ectopic pregnancy, dilation and evacuation, placental
placental abruption and fetal distress. Prenatal labs at six abruption, antepartum hemorrhage, preeclampsia, Cesarean delivery,
weeks showed blood type A negative, antibody screen manual removal of the placenta and external version. ABO
positive: anti-D 1:64. Which of the following is the most incompatibility is immune system reaction that occurs when blood
likely cause of the Rh sensitization? from two different and incompatible blood types are mixed together.
A. ABO incompatibility
B. Placental abruption
C. Amniocentesis
D. Abnormal maternal serum alpha fetoprotein (MSAFP)
E. First trimester bleeding
98. A 28-year-old G3P2 woman presents in C. Placental abruptions, labor augmentation, degree of parity and circumvallate
labor at 39 weeks gestation and delivers placenta have no impact on the risk of retained placenta. The following are associated
a 3500 gram infant spontaneously after with retained placenta: prior Cesarean delivery, uterine leiomyomas, prior uterine
oxytocin augmentation of labor. Thirty curettage and succenturiate lobe of placenta.
minutes later, the placenta has not
delivered. Her past medical history is
significant for leiomyoma uteri. Her
prenatal course was uncomplicated.
What is the most likely risk factor for
retained placenta in this case?
A. Placental abruption
B. Labor augmentation
C. Leiomyomas
D. Multiparity
E. Circumvallate placenta
99. A 28-year-old G3P3 woman experiences C. Uterine atony is the most common cause of postpartum hemorrhage. Risk factors for
profuse vaginal bleeding of 700 cc in uterine atony include precipitous labor, multiparity, general anesthesia, oxytocin use in
one hour following an uncomplicated labor, prolonged labor, macrosomia, hydramnios, twins and chorioamnionitis. Patients at
spontaneous vaginal delivery of a 4150 risk for genital tract lacerations are those who have a precipitous labor, macrosomia or
gram infant. The placenta delivered who have an instrument-assisted delivery or manipulative delivery (i.e. breech
spontaneously without difficulty. Prior extraction). Factors that lead to an over-distended uterus are risk factors for uterine
obstetric history is notable for a inversion. Grand multiparity, multiple gestation, polyhydramnios and macrosomia are all
previous low transverse Cesarean risk factors. The most common etiology of uterine inversion, however, is excessive
delivery, secondary to transverse fetal (iatrogenic) traction on the umbilical cord during the third stage of delivery. Although
lie. The patient had no antenatal the patient is at risk for uterine dehiscence/uterine rupture because of her history of a
complications. Which of the following is prior Cesarean delivery, these are infrequent occurrences so the most likely cause of
the most likely cause of this patient's postpartum hemorrhage in this patient is uterine atony.
hemorrhage?
A. Terbutaline
B. Prostaglandin E1
C. Prostaglandin E2
D. Ampicillin
E. No additional medications required
103. A 29-year-old G1P0 woman at 28 weeks gestation D. Fetal macrosomia, maternal obesity, diabetes mellitus, postterm pregnancy,
who is the wife of basketball player is diagnosed a prior delivery complicated by a shoulder dystocia, and a prolonged second
with gestational diabetes. Her BMI is 23.8. Her stage of labor are all associated with an increased incidence of shoulder
mother had a delivery complicated by shoulder dystocia. Although a family history can be indicative of large babies which
dystocia and she is concerned about her own risk. might place her at additional risk, her gestational diabetes represents her
Which of the following is her biggest risk factor largest risk factor.
for shoulder dystocia?
A. Family history
B. Tall husband
C. Maternal weight
D. Gestational diabetes
E. Parity
104. A 29-year-old G1P0 woman at 31 weeks B. Methods to confirm rupture of membranes include testing the vaginal fluid for
gestation presents with watery discharge from ferning and nitrazine testing. It is important to test the fluid from the vagina and not
the vagina commencing several hours ago. to test cervical mucus because of false positive ferning patterns. A digital exam
Her prenatal course has been uncomplicated should be avoided in a patient you suspect might have preterm rupture of
and she takes prenatal vitamins and iron. She membranes because of the risk of introducing bacteria into the uterine cavity and
denies substance abuse, smoking or alcohol increasing risk for chorioamnionitis. Determination of AFI with ultrasound may
use. On examination, her blood pressure is reveal oligohydramnios and support the diagnosis of rupture of membranes, but
110/70; pulse 84; temperature 98.6F (37.0C). does not confirm this diagnosis. Similarly, a non-stress test may reveal variable
Which of the following is the most appropriate decelerations, which may be present in the setting of rupture of membranes.
next step in the management of this patient?
A. Uteroplacental insufficiency
B. Umbilical cord compression
C. Uterine hyperstimulation
D. Intrauterine growth restriction
E. Fetal head compression
109. A 29-year-old G1P0 woman at 42 weeks gestation A. Initial measures to evaluate and treat fetal hypoperfusion include a change
presents to labor and delivery because of in maternal position to left lateral position which increases perfusion to the
intermittent contractions. She denies ruptured uterus, maternal supplemental oxygenation, treatment of maternal
membranes. Her prenatal course was hypotension, discontinue oxytocin, consider intrauterine resuscitation with
uncomplicated. Her vital signs are: blood pressure tocolytics and intravenous fluids, fetal acid-base assessment with fetal scalp
140/96; pulse 72; afebrile; fundal height 32 cm; capillary blood gas or pH measurement. An amnioinfusion may be used to
and estimated fetal weight of 2900 gm. Cervix is treat patients with variable decelerations. Measures to improve uteroplacental
closed, 25% effaced, -2 station. The fetal heart rate blood flow should be attempted prior to proceeding with Cesarean delivery.
tracing shows occasional late decelerations. Of the Magnesium sulfate is not yet indicated in this patient with one slightly elevated
following, what is the next best step in blood pressure. Augmentation of labor may accentuate the late decelerations.
management?
A. Prevent delivery
B. Delay delivery until fetal lung maturity is reached
C. Delay delivery for one week
D. Delay delivery in order to administer steroids
E. Contraindicated
113. A 29-year-old G2P1 woman at 39 weeks gestation D. Uterine inversion is an uncommon etiology of postpartum hemorrhage.
presents in early labor after spontaneous rupture Factors that lead to an over-distended uterus are risk factors for uterine
of the fetal membranes. Thirty minutes after arrival, inversion. Grand multiparity, multiple gestation, polyhydramnios and
she delivers a 2650 gram male infant. A globular macrosomia are all risk factors. The most common risk factor, however, is
pale mass appears at the introitus when attempting excessive (iatrogenic) traction on the umbilical cord during the third stage of
to deliver the placenta. Her blood pressure is delivery. Although leiomyomas may spontaneously prolapse, it is unlikely
90/60; pulse 104; and temperature is 98.6F (37.0C). during the peripartum period.
What is the most likely etiology for this event in this
patient?
A. Multiparity
B. Twin gestation
C. Leiomyoma
D. Uterine inversion
E. Rapid labor
114. A 29-year-old G3P0 woman presents for prenatal care at B. This patient has an incompetent cervix and should have a cervical
eight weeks gestation. Her two prior pregnancies ended in cerclage at 14 weeks. A positive fetal fibronectin does not indicate
spontaneous losses at 19 and 18 weeks, respectively. incompetent cervix and is used later in pregnancy as a negative
Records corroborate the patient's history of an predictor of preterm delivery. Pregnancy loss in the late second
uncomplicated gestation until the evening of the losses, trimester is not usually related to genetic abnormality of the
when she experienced a pink-tinged discharge that conceptus and most clinicians delay placement of a cerclage until
prompted her to call her obstetrician. In both cases, the after the first trimester, given the high background prevalence of first
obstetrician noted that her cervix had dilated completely trimester pregnancy wastage. Although some clinicians strongly
with the amnionic sac bulging into the vagina to the level support the existence of an antiphospholipid antibody syndrome, the
of the introitus. The patient was afebrile without other term most commonly refers to pregnancy loss or demise, rather than
complaints and there was no uterine tenderness on exam. the clinical scenario of silent cervical dilation with delivery described.
She spontaneously delivered the fetus and placenta in The patient would, therefore, not need aspirin or heparin. Although
both cases. A sonohysterogram confirmed normal uterine some clinicians use prophylactic progesterone to prevent recurrent
anatomy several weeks later. What is the most appropriate abortion, as well as preterm labor, no controlled trials support the use
next step in the management of this patient? of prophylactic progesterone in the treatment of cervical
incompetence.
A. Begin weekly fetal fibronectin testing
B. Placement of a cervical cerclage at approximately 14
weeks gestation
C. Immediate placement of a cervical cerclage
D. Administer low dose aspirin and heparin
E. Administration of prophylactic progesterone
115. A 29-year-old G4P2 woman was diagnosed with twin-twin B. Untreated severe twin-twin transfusion syndrome has a poor
transfusion syndrome when an ultrasound was performed prognosis, with perinatal mortality rates of 70-100%. Death in utero of
at 24 weeks gestational age. Which of the following is a either twin is common. Surviving infants have increased rates of
complication of twin-twin transfusion syndrome? neurological morbidity, including an increased risk of cerebral palsy.
Excessive volume can lead to cardiomegaly, tricuspid regurgitation,
A. Fetal macrosomia in the donor twin ventricular hypertrophy and hydrops fetalis for the recipient twin.
B. Neurologic sequelae in the surviving twin Although the recipient twin is plethoric, it is not macrosomic. The
C. Tricuspid regurgitation in the donor twin donor twin becomes anemic and hypovolemic, and growth is retarded.
D. Heart failure in the donor twin only The recipient twin becomes plethoric and hypervolumic. Either twin
E. High perinatal mortality for donor twin only can develop hydrops fetalis. The donor twin can become hydropic
because of anemia and high-output heart failure.
116. A 29-year-old G4P2 woman with no C. Twin-twin transfusion syndrome is the result of an intrauterine blood transfusion from one
previous prenatal care presents at 24 twin to the other. It most commonly occurs in monochorionic, diamniotic twins. The donor
weeks gestation with signs and twin is often smaller and anemic at birth. The recipient twin is usually larger and plethoric at
symptoms of preterm labor. Her birth. Clues to the presence of the twin-twin transfusion syndrome include the large weight
cervix is 3 cm dilated and 80% discordance (although this is not necessary for diagnosis), polyhydramnios around the larger
effaced. Fundal height is 30 cm and (recipient) twin, and oligohydramnios around the smaller (pump) twin. The two different
an ultrasound examination reveals a placental types in twin gestation are monochorionic and dichorionic. Monozygotic
twin gestation. Estimated fetal conceptions may have either monochorionic or dichorionic placentation, depending upon
weights on the twins are 850 gm and the time of division of the zygote. Dizygotic conceptions always have dichorionic placentas.
430 gm. The maximum vertical Diamniotic dichorionic placentation occurs with division prior to the morula state (within
amniotic fluid pocket around the three days post fertilization). Diamniotic monochorionic placentation occurs with division
smaller twin is 1 cm; the maximum between days four and eight post fertilization. Monoamniotic, monochorionic placentation
vertical amniotic fluid pocket around occurs with division between days eight and 12 post fertilization. Superfecundation is the
the larger twin is 8 cm. Which of the fertilization of two different ova at two separate acts of intercourse in the same cycle.
following is the most likely Isoimmunization is associated with polyhydramnios and fetal hydrops and does not cause
associated with these ultrasound twin-twin transfusion.
findings?
A. Bed rest
B. Cervical cerclage
C. Tocolytics starting at 24
weeks
D. Home uterine monitoring
E. Early, good weight gain
127. A 32-year old G1P0 woman at 29 B. Maternal indomethacin exposure can result in premature constriction of the ductus
weeks gestation presents with arteriosus, especially if used after 32 weeks gestation. Polyhydramnios is not associated with
preterm labor. She is started on indomethacin. In fact, indomethacin is associated with oligohydramnios. Fetal hypoxia and
indomethacin. What is a possible decreased uteroplacental blood flow have been associated with the use of calcium channel
adverse fetal effect associated with blockers, such as Nifedipine. Indomethacin should not cause chorioamnionitis.
indomethacin treatment?
A. Polyhydramnios
B. Premature constriction of the
ductus arteriosus
C. Fetal growth restriction
D. Hypoxia
E. Chorioamnionitis
128. A 32-year-old G1P0 woman comes to B. The rate of vaginal birth after Cesarean (VBAC) has decreased in recent years due to
your office for her first prenatal care studies that showed an increased risk of complications, especially uterine rupture. This is one
visit. She has recently read an article factor that has led to the increased Cesarean section rate. In addition, although the rate of
about the rising Cesarean section breech and other abnormal presentation is stable, there are significantly fewer obstetricians
rate in the United States and asks you who are willing to perform vaginal breech deliveries (due in part to a lack of training in
about the rate in your hospital. What vaginal breech deliveries). Many obstetricians do not perform instrumental vaginal
do you explain as the major cause of deliveries, such as forceps and vacuum extractions, further contributing to the rising rate.
higher Cesarean delivery rates? Gestational diabetes is a well-known pregnancy complication with clear clinical guidelines.
A. Sitz baths
B. Whirlpool therapy
C. Debridement
D. Repair of laceration site
E. Incision and drainage of perineal laceration
131. A 32-year-old G1 presents at 35 weeks gestation with decreased A. Since the patient reported decreased fetal movement, a
fetal movement. Her prenatal course has been complicated by size non-stress was performed and was reassuring. The NST is
less than dates. Serial ultrasounds show a decrease of the estimated based on the principle that when the fetus moves, its
fetal weight from 60th to 20th percentile. The non-stress test is heartbeat normally accelerates. The NST assesses fetal
reactive and the amniotic fluid index is 10. What is your next step in health through monitoring accelerations of the heart rate in
management? response to the baby's own movements. Amniotic fluid
A. Continue with weekly non-stress tests volume is important because a decreased amount raises the
B. Obtain umbilical artery systolic: diastolic ratio possibility that the fetus may be under stress. Since the fetus
C. Admission for daily fetal surveillance does not show growth restriction and fetal status was
D. Induction of labor today reassuring, there are no indications for Doppler studies or
E. Cesarean section today delivery. In light of the dramatic decrease in growth, it is
reasonable to follow this patient with weekly non-stress
tests.
132. A 32-year-old G2P1 woman at 36 weeks gestation B. In this patient, the benefits for delivery outweigh the risk of expectant
presents with preterm premature rupture of the management, so the patient should undergo augmentation of labor.
membranes that occurred 36 hours ago. She denies Expectant management at 36 weeks poses a large risk to the
labor. She takes prenatal vitamins and iron. She denies development of chorioamnionitis. The role of tocolytics in the setting of
substance abuse, smoking or alcohol use. Her prior preterm premature rupture of membranes is controversial and is
pregnancy delivered vaginally at 34 weeks after contraindicated at 36 weeks gestation. Steroid administration after 32
spontaneous rupture of membranes. Her blood pressure weeks is controversial.
is 110/70; pulse 84; temperature 98.6F (37.0C). The
estimated fetal weight is 2700 grams. She is having one
contraction per hour and fetal heart tracing is Category
I. Which of the following is the most appropriate next
step in the management of this patient?
A. Placental abruption
B. Placenta previa
C. Bloody show
D. Cervical cancer
E. Cervicitis
138. A 32-year-old G5P3 woman presents with left-sided abdominal pain. Her last D. This scenario is consistent with the patient
normal menstrual period was eight weeks ago. She began having pain early this having a ruptured ectopic pregnancy. Signs of
morning and it has increased to a severity of 8/10. She denies nausea or vomiting hypovolemia (tachycardia, hypotension) with
or vaginal bleeding. Her gynecological history is notable for a right-sided peritoneal signs (rebound, guarding and
ectopic pregnancy four years ago. At that time, she had a right salpingectomy severe abdominal tenderness) and a positive
and a left tubal ligation. On physical examination: blood pressure is 90/54; pulse pregnancy test lead to the diagnosis of
108; respirations 22; and temperature 98.6F (37.0C). On abdominal examination, ruptured ectopic pregnancy. Conservative
she has rebound and guarding in all quadrants, and on pelvic exam, her uterus is management, with observation and repeating
very tender and there is left adnexal fullness. Urine pregnancy test is positive. A the Beta-hCG level in 48 hours is not indicated
transvaginal ultrasound shows a thickened endometrium, left pelvic mass with a since a diagnosis is clear and delaying surgery
gestational sac and fetal pole, and a large amount of free fluid in the pelvis. Her can potentially be dangerous to the patient.
hematocrit is 26%. What would be the next best step in the management? Dilation and curettage would only be
considered after laparoscopy, if needed.
A. Admit for observation
B. Repeat Beta-hCG level in 48 hours
C. Treat with methotrexate
D. Perform a laparoscopy
E. Perform a dilation and curettage
139. A 33-year-old G1P0 woman at 38 weeks gestation with pregnancy complicated D. This fetus is clearly not tolerating labor.
by type 1 diabetes was admitted for induction due to oligohydramnios. She Unfortunately, there is no good way to assess
received Cervidil (prostaglandin E2) overnight and her cervix was noted to be 3 fetal status at this point. A biophysical profile is
cm dilated in the morning so oxytocin was started. After three hours on oxytocin not of any value in labor. Amnioinfusion may
induction, fetal heart rate was noted to be in the 160s with minimal variability and be used for repetitive variable decelerations
late decelerations despite resuscitation with oxygen, fluids and left lateral and not for recurrent lates. The presence of
position. Thirty minutes after discontinuing the oxytocin, she continued to have late decelerations in a patient with diabetes
contractions every three to four minutes with late decelerations. Her blood and oligohydramnios is not reassuring and
pressure was noted to be 138/88 and her pulse was 110. Her cervical exam was unlikely to recover. Although terbutaline may
noted to be 4 cm dilated. What is the most appropriate next step in the slow down the contractions, it is not
management of this patient? recommended in a patient whose heart rate is
110.
A. Perform a biophysical profile
B. Begin amnioinfusion
C. Administer terbutaline
D. Proceed with a Cesarean section
E. Restart the oxytocin
140. A 33-year-old G2P1 presents at 34 weeks The fetus with enhanced general growth or macrosomia is defined by a birth weight
gestation for consultation because at or above the 90th percentile for gestational age. The condition can usually be
ultrasound revealed a 3900 gm fetus with ascribed to one of three etiologies: enhanced growth potential (50-60%); abnormal
biometrics consistent with 39 weeks. Her maternal glucose homeostasis (35-40%); or underestimation of fetal age (5%).
prior pregnancy was complicated by Macrosomic newborns of diabetic mothers experience excessive rates of neonatal
gestational diabetes and a shoulder dystocia. morbidity, including birth trauma such as shoulder dystocia and brachial plexus
Which of the following complications is this injury. These infants have significantly higher rates of severe hypoglycemia and
fetus at greatest risk? neonatal jaundice. Neonatal acidosis occurs with poor glycemic control, thus
increasing the incidence of fetal demise. While poorly controlled pre-existing
A. Birth trauma diabetes is associated with an increased risk of congenital anomalies, gestational
B. Hyperglycemia diabetes is not associated with increased risk of congenital anomalies.
C. Hypobilirubinemia
D. Hypothyroidism
E. Congenital anomalies
141. A 33-year-old G2P1 presents at 36 weeks C. Delivery is indicated in a fetus with IUGR at 36 weeks gestation with
gestation for consultation because oligohydramnios and abnormal umbilical artery Doppler studies. Although there is
ultrasound revealed a fetus with biometry an increased incidence of fetal intolerance of labor, induction of labor is generally
consistent with 30 5/7 weeks gestation. The preferred over elective Cesarean delivery. Delivery at term is indicated in fetuses
EFW is less than the 5th percentile. Umbilical with IUGR with reassuring fetal testing including a normal amniotic fluid volume.
artery Doppler studies are abnormal. There
is reverse end diastolic flow and the amniotic
fluid volume is decreased. The AFI is 1.1 cm.
Which of the following is the most
appropriate next step in the management of
this patient?
A. Close observation with twice weekly NSTs
and amniotic fluid assessments
B. Close observation with twice weekly NSTs,
amniotic fluid assessments and weekly
umbilical artery Doppler studies
C. Induction of labor
D. Induction of labor at term (37 weeks
gestation)
E. Delivery by Cesarean section
142. A 33-year-old G2P1 woman at 29 weeks A. Antibiotic therapy with ampicillin and erythromycin given to patients with preterm
gestation presents with confirmed preterm premature rupture of the membranes has been found to prolong the latency period
premature rupture of membranes. She denies by 5-7 days, as well as reduce the incidence of maternal amnionitis and neonatal
labor. She takes prenatal vitamins and iron. sepsis. Clindamycin and gentamicin are not indicated for the management of
She denies substance abuse, smoking or PPROM. Tocolytics may also prolong the pregnancy for various lengths of time, but
alcohol use. Her prior pregnancy was generally not seven days.
delivered vaginally at 41 weeks after
spontaneous rupture of membranes. Her
blood pressure is 110/70; pulse 84;
temperature 98.6F (37.0C). Which of the
following is the next best step in the
management of this patient?
A. Age
B. History of chlamydia infections
C. History of ectopic pregnancy
D. Prior Cesarean delivery
E. Interval between pregnancies
148. A 34-year-old chronic hypertensive G1 comes to see D. Uteroplacental insufficiency can lead to asymmetric growth restriction.
you for a consultation at 34 weeks for size less than Asymmetric growth restricted infants typically have a normal length, but
dates. Her prenatal course has been uncomplicated their weight is below normal. On ultrasound, there is a head-sparing effect,
and the genetic amniocentesis obtained at 15 weeks meaning that the head/brain is spared of the reduced blood flow that is a
revealed a normal male. Biometrics today reveal a result of uteroplacental insufficiency. Thus, the fetal abdomen measures
biparietal diameter consistent with 33 weeks, below normal and the head remains very close to normal. There is an
abdominal circumference of 28 weeks, EFW 1600 g, asymmetrical growth pattern that is usually detected during the third
less than 10th percentile, and an amniotic fluid index trimester and reflects uteroplacental insufficiency.
of 6. What is the most likely cause of fetal growth Symmetric fetal growth restriction indicates that all fetal measurements are
restriction in this patient? below normal. As a general rule, such a finding indicates an intrinsic growth
A. Chromosomal abnormality failure or an "early event" secondary to one or more organ system
B. Fetal infection with Rubella anomalies, fetal aneuploidy or chronic intrauterine infection. Infectious
C. Fetal infection with cytomegalovirus (CMV) diseases are known to cause IUGR, but the number of organisms is poorly
D. Uteroplacental insufficiency defined. There is sufficient evidence to show a causal relationship between
E. Maternal infection with Varicella rubella and CMV infections and fetal growth restriction. Other viruses to
consider are syphilis and varicella. The protozoan toxoplasmosis results in
IUGR as well. There are no bacteria known to cause IUGR. Symmetrical
growth restriction is usually detected in the mid-trimester of pregnancy.
149. A 34-year-old G1P0 woman is diagnosed with a fetal B. Couples who are presented with the news of a fetal birth defect or loss
demise at 37 weeks. She and her husband seem progress through a series of coping responses. The response to "bad news"
stunned. They cannot believe the news. What is the varies with the severity, treatability and the coping level of the couple. As an
next psychological response you would expect from individual starts to understand the situation, frustration or anger may be
this couple after the initial denial? self-directed or directed to the spouse, the affected child or the caregiver
without a rational basis. This is important to recognize to help the couple
A. Depression through these stages: Denial, Anger, Bargaining, Depression, Acceptance.
B. Anger
C. Assessment
D. Bargaining
E. Acceptance
150. A 34-year-old G1P0 woman is in a motor vehicle B. The risk of developing microcephaly and severe intellectual disability
accident. While in the emergency department, the is greatest between eight and 15 weeks gestation. In 1990, the
doctors order multiple x-rays to evaluate her injuries. At Committee on Biological Effects reported that no risk of mental
what gestational age would the fetus be most retardation (now referred to as intellectual disability) has been
susceptible to developing intellectual disability with documented with doses even exceeding 50 rad at less than eight weeks
sufficient doses of radiation? or greater than 25 weeks gestation.
A. 0-7 weeks
B. 8-15 weeks
C. 16-25 weeks
D. 26-30 weeks
E. 31-35 weeks
151. A 34-year-old G1P0 woman presents with vaginal E. Patients experiencing early pregnancy loss can safely consider
spotting. On physical exam: blood pressure 120/70; pulse several different treatments, including expectant management, medical
82; respirations 20; and temperature 98.6F (37.0C). An treatment to assist with expulsion of the pregnancy or surgical
ultrasound confirms a non-viable intrauterine pregnancy. evacuation. Provided the patient is hemodynamically stable and reliable
She is otherwise healthy. Her partner accompanies her for follow-up, expectant management is appropriate therapy. At the
and is supportive. The patient wishes to avoid any gestational age described, expectant management portends no
unnecessary medical interventions and asks whether she increase in risk of either hemorrhage or infection compared with
can safely let nature take its course. What is the best surgical or medical evacuation. Regardless of method chosen, the
next step in the management of this patient? patient's blood type should be checked and rhogam administered as
indicated.
A. Immediate dilation and suction curettage
B. Dilation and suction curettage in one week
C. Immediate treatment with misoprostol
D. Treatment with misoprostol in one week
E. Expectant management
152. A 34-year-old G1 woman at eight weeks gestation D. Screening should be performed between 24 and 28 weeks in those
presents for prenatal care. She is healthy and takes no women not known to have glucose intolerance earlier in pregnancy. This
medications. Family history reveals type 2 diabetes in evaluation can be done in two steps: a 50-g oral glucose challenge test
her parents and brothers. She is 5 feet 2 inches tall and is followed by a diagnostic 100-g oral glucose tolerance test (OGTT) if
weighs 220 pounds (BMI 40.2 kg/m2). Which of the initial results exceed a predetermined plasma glucose concentration.
following is the best recommendation to screen her for Patients at low risk are not routinely screened. For those patients of
gestational diabetes? average risk screening is performed at 24-28 weeks while those at high
risk (severe obesity and strong family history) screening should be done
A. Screen at 24-28 weeks with a 50-g oral glucose as soon as feasible.
challenge test
B. Screen at 16-20 weeks with a 50-g oral glucose
challenge test
C. Screen at 12 weeks with a 50-g oral glucose challenge
test
D. Screen now with a 50-g oral glucose challenge test
E. Begin an oral hypoglycemic agent now
153. A 34-year-old G2P1 woman at 18 weeks gestation presents E. There is no doubt that breast cancer is more aggressive in younger
with a newly discovered lump in her left breast. Fine women. Whether it is more aggressive during pregnancy in young
needle aspiration reveals adenocarcinoma. Which of the women is debatable. Slight delays (1 to 2 months) in clinical
following is the least likely recommended therapy for assessment, diagnostic procedures, and treatment of pregnant women
breast cancer during pregnancy? with breast tumors are common. Approximately 30 percent of
pregnant women with breast cancer have stage I disease, 30 percent
A. Wide local excision biopsy have stage II, and 40 percent stages III or IV. Many clinical reports
B. Modified radical mastectomy maintain that when breast cancer is diagnosed during pregnancy, the
C. Total mastectomy and node dissection regional lymph nodes are more likely to contain microscopic
D. Chemotherapy metastases. Surgical treatment may be definitive for breast carcinoma
E. Radiotherapy during pregnancy and in the absence of metastatic disease a wide
excisional biopsy, modified radical mastectomy, or total mastectomy
with axillary node staging can be performed. Non-pregnant women
receive adjunctive radiotherapy with breast-conserving surgery.
However, this is not recommended during pregnancy due to sizeable
abdominal scatter placing the fetus at significant risk for excessive
radiation.
154. A 34-year-old G2P1 woman at 40 weeks gestation with a B. The patient is multiparous at term and waiting until she reaches 42
history of one prior vaginal delivery strongly desires an weeks may increase the risk of perinatal mortality. Since she is
induction of labor, as she is unable to sleep secondary to uncomfortable with back pain, it is reasonable to induce labor. Her
severe back pain. Her cervical exam is closed, 20% cervix is unfavorable; therefore, cytotec administration is appropriate
effaced and -2 station. The cervix is firm and posterior. prior to pitocin induction. A foley bulb or artificial rupture of
Which of the following is the most appropriate next step in membranes cannot be achieved in a patient with a closed cervix. At
the management of this patient? this time, there are no indications to perform a Cesarean delivery in
this patient.
A. Wait until 42 weeks for induction
B. Administer cytotec
C. Insert a foley bulb in the cervix
D. Perform artificial rupture of membranes
E. Perform a Cesarean delivery
155. A 34-year-old G4P3 woman at 19 weeks gestation A. This patient is in thyroid storm, an acute, life-threatening,
presents to the emergency department with chest pain, hypermetabolic state. Radioactive iodine (I-131) concentrates in the
palpitations and sweating, which began 2-3 hours ago. On fetal thyroid and may cause congenital hypothyroidism, so it should
further questioning, she states that she has been very not be intentionally used in pregnancy. Acute treatment of thyroid
anxious lately and is not sleeping well, which she storm may include thioamides (i.e. PTU), propranolol, sodium iodide
attributes to the pregnancy. She reports that she has lost and dexamethasone. Oxygen, digitalis, antipyretics and fluid
40 pounds in the last year without trying. She denies replacement may also be indicated. Maternal mortality with thyroid
significant medical problems. On exam, the patient storm exceeds 25%.
appears diaphoretic and anxious, her eyes are wide open,
prominent, with easily visible sclera surrounding the pupil.
Vital signs are: temperature 100.2F (37.9C); pulse 132;
and blood pressure 162/84. Her height is 5 feet 10 inches
and weight is 128 pounds. Her thyroid is palpably
enlarged, with an audible bruit. Electrocardiogram shows
sinus tachycardia. Remaining labs are pending. Which of
the following therapies is contraindicated at this time?
A. Autosomal trisomy
B. Triploidy
C. Tetraploidy
D. Monosomy X (45X,0)
E. Fragile X mutation
160. A 36-year-old female G1 presents for A. When a pregnancy is complicated by fetal growth restriction, various fetal physiologic
her prenatal care visit at 35 weeks parameters require assessment. In growth-restricted pregnancies, oligohydramnios is
gestation. She has good dating criteria frequently found. This finding is presumably due to reduced fetal blood volume, renal
that were confirmed by a first trimester blood flow and urinary output. Chronic hypoxia is responsible for diverting blood flow
ultrasound. Her previous medical from the kidney to organs that are more critical during fetal life. The significance of the
history is positive for hypertension and amniotic fluid volume with respect to fetal outcome has been well documented. Ninety
type 2 diabetes. You have been percent of patients with oligohydramnios delivered growth restricted infants. These
following fetal growth with serial infants experienced a high rate of fetal compromise. The systolic/diastolic (S/D) ratio of
ultrasounds. At this visit, ultrasound the umbilical artery is determined by Doppler ultrasound. An increase in the S/D ratio
reveals limited fetal growth over the reflects increased vascular resistance. It is a common finding in IUGR fetuses. A normal
past three weeks. Biometry is S/D ratio indicates fetal well-being. As vascular resistance increases, the S/D ratio
consistent with 32-5/7, EFW 2175 g, increases. With severe resistance, there is absence and ultimately reversal of end-diastolic
<10th percentile. What is the most flow. These findings are associated with an increased rate of perinatal morbidity and
appropriate next test indicated in the mortality, and a higher likelihood of a long-term poor neurologic outcome. Options for
management of this patient? antenatal testing include the non-stress test, contraction stress test, and the biophysical
A. Amniotic fluid volume, umbilical profile. Any of these may be used in a growth-restricted fetus as a means of detecting
artery Doppler systolic: diastolic ratio, possible or probable fetal asphyxia. While fetal kick counts may be of value, additional
non-stress test fetal testing such as twice weekly NST with AFI and weekly umbilical artery Doppler
B. Daily fetal kick counts with follow up studies is indicated in monitoring fetuses with IUGR.
ultrasound to reassess fetal growth in
one week
C. Amniocentesis for fetal lung maturity
D. Twice daily fetal kick counts with
delivery at 37 weeks gestation
E. None, delivery is indicated
161. A 36-year-old G1 began prenatal care D. There is substantial evidence from experimental animal studies that suggests that
at eight weeks gestation. At that time, alterations in uteroplacental perfusion affect the growth and status of the fetus, as well as
the gestational age was confirmed by a the placenta. This patient has significant medical diseases that are affecting her
transvaginal ultrasound. She is now at vasculature and, ultimately, limiting the substrate availability to the fetus with resultant
36 weeks gestation. Her previous uteroplacental insufficiency. The vascular disease is evidenced by retinopathy and
medical history reveals hypertension proteinuria. The other choices above may all result in fetal growth restriction; however,
for eight years and class F diabetes for they are not the most likely etiology in this clinical scenario.
five years (baseline proteinuria = 1 g).
She smokes one half-pack of cigarettes
per day. On examination at 32 weeks
gestation, her fundal height was 29 cm.
At 33 weeks, biometry was consistent
with 31-3/7, EFW 1827g, 25th percentile.
Today, ultrasound reveals limited fetal
growth over the past three weeks.
Biometry is consistent with 31-5/7, EFW
1900 g, <10th percentile. What is the
most likely etiology of the intrauterine
growth restriction in this case?
A. Genetic factors
B. Congenital anomaly
C. Tobacco use
D. Uteroplacental insufficiency
E. Perinatal infection
162. A 36-year-old G1P0 woman presents in active B. Methergine, prostaglandins, misoprostol, and oxytocin are all uterotonics
labor. Her past medical history and prenatal and used to increase uterine contractions and decrease uterine bleeding.
course were complicated by chronic Methylergonovine is an ergot alkaloid, which is a potent smooth muscle
hypertension and superimposed preeclampsia. constrictor. It is also a vasoconstrictive agent and should be withheld from
She received magnesium sulfate for seizure women with hypertension and/or preeclampsia. Misoprostol, prostaglandin E1,
prophylaxis and oxytocin augmentation. She used for cervical ripening and labor induction, is a uterotonic agent frequently
undergoes an uneventful spontaneous vaginal used for uterine atony, although not FDA approved for this use.
delivery. Postpartum, she has a 1000 ml
hemorrhage due to uterine atony. Her blood
pressure is 130/80; pulse 96; and she is afebrile.
Which of the following uterotonic agents is
contraindicated in this patient?
A. Oxytocin
B. Methylergonovine
C. Prostaglandin F2-alpha
D. Prostaglandin E2
E. Misoprostol
163. A 36-year-old G1 with type 1 diabetes is D. Once intrauterine growth restriction is detected, the fetus needs to be
diagnosed with intrauterine growth restriction at evaluated periodically for evidence of well-being until delivery is deemed
33 weeks gestation. What is the most appropriate necessary. This will result in once or twice weekly testing, depending on the
next step in management? modality of assessment that is being used. Testing includes: non-stress test
A. Amniocentesis (NST), where the fetal heart beat is recorded over a period of at least 30
B. Immediate delivery minutes while looking for accelerations with fetal movement, and the
C. Weekly ultrasounds to assess fetal growth biophysical profile, which includes an ultrasound evaluation of fetal movement,
D. Antenatal testing of fetal well-being fetal tone, amniotic fluid and breathing. NSTs should be performed twice
E. Observation weekly with at least a weekly AFI. The BPP may be performed weekly.
Ultrasound for fetal growth is not useful if more frequent than every two weeks.
An amniocentesis for fetal lung maturity can be considered at more advanced
gestational age.
164. A 36-year-old G2P1 woman presents for her first D. Amitriptyline, levothyroxine, labetalol and acyclovir are medications that are
prenatal visit at 11 weeks gestation. She has a frequently used in pregnancy and are felt to have acceptable safety profiles.
two-year history of chronic hypertension treated The use of angiotensin converting enzyme inhibitors, such as Lisinopril, beyond
with lisinopril and labetalol. In addition, she has the first trimester of pregnancy has been associated with oligohydramnios, fetal
hypothyroidism treated with levothyroxine, and growth retardation and neonatal renal failure, hypotension, pulmonary
recurrent herpes, for which she is on chronic hypoplasia, joint contractures and death. Amitriptyline is used in pregnancy to
acyclovir suppressive therapy. She takes treat migraine headaches.
amitriptyline for migraine headaches. Which of
her medications is contraindicated in pregnancy?
A. Levothyroxine
B. Labetalol
C. Acyclovir
D. Lisinopril
E. Amitriptyline
165. A 36-year-old G5P4 woman with no D. Although all the options above can result in third trimester vaginal bleeding, the
prenatal care presented in active labor most likely cause in this patient is placental abruption. This diagnosis goes along with
with a blood pressure of 170/105 and 3+ the tachysystole on tocometer and evidence of fetal anemia (tachycardia and
proteinuria. Fundal height is 28 cm. Fetal sinusoidal heart rate pattern) on the heart rate tracing. Hypertension and preeclampsia
heart tones were found to be in the 170s are risk factors for abruption. She has no history of cervical trauma.
with decreased variability and a
sinusoidal pattern. Resting uterine tone
was noted to be increased and she was
having frequent contractions (every 1-2
minutes). The patient complained of bright
red vaginal bleeding for the past hour.
Based on this history, what is the most
likely etiology of her vaginal bleeding?
A. Uterine rupture
B. Placenta previa
C. Bloody show
D. Abruptio placentae
E. Cervical trauma
166. A 37-year-old G2P1 woman with poorly A. After ensuring appropriate backup, establishing intravenous access and stabilizing a
controlled chronic hypertension presents patient as needed, the first steps in the management of postpartum hemorrhage are to
in labor at term. Her prenatal course was make sure the uterus is well-contracted, there is no retained placental tissue and to
uncomplicated. She delivers a 3500 gram look for lacerations. This patient has a firm fundus, which indicates a contracted uterus.
infant spontaneously after oxytocin Her placenta is complete, which typically rules out retained placental tissue, so it is
augmentation of labor. Immediately important to rule out lacerations, which can lead to hemorrhage. Methylergonovine,
postpartum, she experiences excessive prostaglandins and oxytocin are all uterotonics and used to increase uterine
bleeding. Her blood pressure is 130/90; contractions and decrease uterine bleeding. Methylergonovine is an ergot alkaloid,
pulse 84; and she is afebrile. On which is a potent smooth muscle constrictor. It is also a vasoconstrictive agent and
examination, uterine fundus is firm and should be withheld from women with hypertension and/or preeclampsia. B Lynch
the placenta is intact. Which of the suture is used at time of laparotomy for uterine atony. Oxytocin should not be given as
following is the most appropriate next an IV push. Uterine artery embolization can be considered after other sources of
step in the management of this patient? bleeding such as lacerations are ruled out.
A. Oxytocin
B. Rupture of membranes
C. Abruptio placentae
D. Chorioamnionitis
E. Normal labor progression
173. A 39-year-old G4P1 woman at 36 weeks gestation presents to D. Uncontrolled diabetes during organogenesis is associated with a
labor and delivery. Upon initial evaluation, no fetal heart high rate of birth defects. The most common sites affected are the
tones were noted on Doptone. Ultrasound confirms fetal spine and the heart of the fetus, although all birth defects are
demise. Problems during the pregnancy include diagnosis of increased. Fetuses in utero exposed to high levels of glucose
an open neural tube defect, estimated fetal weight >90th transplacentally have increased growth and polyuria resulting in an
percentile, polyhydramnios and a nonreactive NST (non- increase in the amniotic fluid. While some viral infections are also
stress test) the week prior to admission. What is the most associated with placentomegaly and polyhydramnios, the fetus will
likely etiology of this fetal demise? have normal or decreased growth depending on the timing of the
infection. Severe hypertension and active APAS is often associated
A. Uncontrolled hypertension with oligohydramnios and intrauterine growth restriction. The risk of
B. In-utero viral infection miscarriage is increased if hypothyroidism goes untreated.
C. Antiphospholipid antibody syndrome (APAS)
D. Uncontrolled diabetes
E. Untreated maternal hypothyroidism
174. A 40-year-old G1P0 woman at 22 weeks gestation presents to B. The most likely cause of painless cervical dilation which leads to
the office with a complaint of pelvic pressure. She reports pelvic pressure, bulging membranes and fetal loss is cervical
that she had intercourse the night prior to presentation and incompetence or insufficiency. This patient has a history of cone
noted some mucous mixed with blood this morning. Her biopsy which can lead to cervical incompetence. Preterm labor by
history is significant for type 1 diabetes and she is on an definition does not occur until 24 weeks gestation. Although
insulin pump. Her surgical history is significant for a history of uncontrolled diabetes can lead to fetal malformations and early
cone biopsy for treatment of abnormal Pap smear three miscarriage, it is not typically a cause of fetal loss in the second
years ago. On examination, her BMI is 26. She is noted to have trimester. Advanced maternal age is associated with an increased
a 2 cm dilated cervix with bulging membranes that rupture risk of stillbirth, preeclampsia, gestational diabetes and intrauterine
upon placing the speculum. Fetal parts are noted in the growth restriction.
vagina. What is the most likely cause of this finding?
A. Uncontrolled diabetes
B. Cervical incompetence/insufficiency
C. Preterm labor
D. Advanced maternal age
E. Infection
175. A 40-year-old G1P0 woman at 34 3/7 weeks gestation was found on A. Magnesium sulfate is the treatment of choice for
the floor at work having a grand mal seizure. Her airway was secured. eclampsia, which is her most likely diagnosis. Valium,
Blood pressure in the ambulance was 140/90. What is the initial hydantoin, tiagabine, and barbiturates can also be used to
treatment for her condition? treat seizures, but are not first-line therapy for eclampsia.
They can be added as second agents, or used if
A. Magnesium sulfate magnesium is contraindicated. Naloxone (Narcan) is a
B. Valium drug used to counter the effects of opioid overdose, for
C. Hydantoin example heroin or morphine overdose, and is specifically
D. Phenobarbital used to counteract life-threatening depression of the
E. Naloxone central nervous system.
176. A 40-year-old G6P5 woman delivered a 5020 grams live born male C. This patient has uterine atony, which accounts for about
infant vaginally 20 minutes ago. The nurse notes that the patient is 80-90% of all postpartum hemorrhages. Risk factors for
having ongoing bleeding that she estimates to be 1000 cc. Her past PPH include uterine over distension (polyhydramnios,
medical history is significant for chronic hypertension and asthma. She macrosomia, and multiple gestation), prolonged labor,
has received oxytocin and misoprostol. Her examination reveals a chorioamnionitis, and grandmultiparity. This patient has
boggy uterus. Which of the following is the next step in management already received uterotonic agents and while additional
of her bleeding? agents are available, because of her hypertension and
asthma both methergine and prostaglandin F2 alpha are
A. Uterine artery embolization contraindicated. All of the choices listed are treatments,
B. B-Lynch compression stitch the least invasive treatment is placement of the Bakri
C. Bakri balloon placement balloon, which is a device placed into the uterus with a
D. Uterine artery ligation balloon that is filled with up to 500 cc of sterile fluid. This
E. Hysterectomy places pressure on the inside of the uterus. Uterine artery
ligation, B-lynch compression stitch and hysterectomy all
require a laparotomy and should be reserved for
recalcitrant cases. Uterine artery embolization requires
placement of embolization catheters as well as
interventional radiology.
177. A 41-year-old G3P2 woman presents with cramping, vaginal bleeding B. The diagnosis of ectopic pregnancy is made when
and right lower quadrant pain for five days which has progressively either: 1) a fetal pole is visualized outside the uterus on
worsened. Her last normal menstrual period occurred seven weeks ultrasound; 2) the patient has a Beta-hCG level over the
ago. Her surgical history is notable for a bilateral tubal ligation discriminatory zone (the level at which an intrauterine
following her last delivery. On physical exam, vital signs are: blood pregnancy should be seen on ultrasound, usually 2000
pressure 110/74; pulse 82; respirations 18; temperature 98.6F (37.0C). mIU/ml) and there is no intrauterine pregnancy (IUP) seen
On abdominal exam, she has right lower quadrant tenderness, with on ultrasound; or 3) the patient has inappropriately rising
rebound and bilateral guarding in the lower quadrants. On pelvic Beta-hCG level (less than 50% increase in 48 hours) and
exam, she has scant old blood in the vagina and a normal appearing has levels which do not fall following diagnostic dilation
cervix. Her uterus is normal size and slightly tender. She has cervical and curettage. This patient meets criteria #2, as her Beta-
motion tenderness on bimanual examination, and marked tenderness hCG is >2000 mIU/ml with no intrauterine pregnancy seen
on rectal examination. Her quantitative Beta-hCG is 4000 mIU/ml; on ultrasound. The history, physical exam and lab data are
progesterone 6.2 ng/ml; hematocrit 34%; and WBC 15,400/mcL, with not consistent with pelvic inflammatory disease, ovarian
88% segmented neutrophils and no bands. The transvaginal ultrasound torsion, appendicitis or a ruptured corpus luteum cyst.
shows an empty uterus with endometrial thickening, a mass in right With a heterotopic pregnancy, there should be a visible
ovary measuring 3.8 x 2 cm, and a small amount of free fluid in the pregnancy in the uterus. With a missed abortion there
pelvis. What is the most likely diagnosis in this patient? should also be some visible tissue or a fetal pole within
the uterus.
A. Pelvic inflammatory disease
B. Ectopic pregnancy
C. Heterotopic pregnancy
D. Missed abortion
E. Ruptured corpus luteum cyst
178. A 42-year-old G5P2 woman at 36 weeks gestation is diagnosed with E. The previous history of spontaneous abortion does
preeclampsia. Her previous pregnancy was complicated by twins and not put the patient at increased risk. The incidence of
preeclampsia at 36 weeks gestation. She also has had two spontaneous preeclampsia is commonly cited to be about 5 percent
abortions at seven weeks gestation. Which of the following conditions is and is markedly influenced by parity. It is related to race,
not associated with her increased risk for preeclampsia in this ethnicity and genetic predisposition. Environmental
pregnancy? factors are also likely to play a role. Other risk factors
for preeclampsia include a previous history of the
A. Previous history of preeclampsia disease, chronic hypertension, multifetal pregnancy and
B. Chronic hypertension molar pregnancy. In addition, patients at extremes of
C. Multifetal pregnancy maternal age or with diabetes, chronic renal disease,
D. Age antiphospholipid antibody syndrome, vascular or
E. Previous spontaneous abortion connective tissue disease or triploidy are at increased
risk for developing preeclampsia
179. A 45-year-old G4P3 woman presents with vaginal bleeding. Last week, D. Cervical cancer can unfortunately complicate
she performed a home pregnancy test that was positive. She thinks her pregnancies and presents with bleeding. She is at risk
last menstrual period was four months ago. The last time she saw her due to lack of screening as well as her history of
doctor was eight years ago, with the birth of her last child. She has no smoking. Other causes of bleeding need to be ruled out
serious medical problems, has smoked a pack of cigarettes a day since such as cervical incompetence, infection or trauma.
the age of 20, occasionally has a beer and does not exercise. Treatment for cervical cancer during pregnancy requires
Abdominal examination reveals a soft abdomen and the fundus difficult decisions that consider the stage of cancer,
palpable just below the umbilicus. Pelvic ultrasound reveals a fundal appropriate therapy, maternal welfare and fetal welfare.
placenta and a fetus measuring 18 weeks with normal cardiac activity. Cervical polyps occur during pregnancy and can be a
Vaginal examination reveals a 3-centimeter lesion on the posterior lip cause of bleeding, but are typically soft and not hard or
of the cervix. It easily bleeds with palpation and is hard in consistency. nodular on examination. Nabothian cysts are very
Which of the following is the most likely cause of the bleeding? common, but do not typically cause bleeding.
A. Cervicitis
B. Cervical polyp
C. Endometrial polyp
D. Cervical cancer
E. Nabothian cyst
180. Thirty-six hours ago a 23-year-old G1P1 woman delivered vaginally and B. Endomyometritis is a common complication of
sustained a 2nd-degree laceration. She had a prolonged first stage of prolonged labor, prolonged rupture of membranes and
labor, ruptured membranes for 26 hours and received penicillin for multiple vaginal examinations. The infection is
group B Strep prophylaxis. She now complains of increasing abdominal polymicrobial, mostly anaerobic and requires broad-
pain, cramping and heavy, foul-smelling lochia. Her vital signs reveal a spectrum antibiotics for treatment until the patient is
temperature of 100.0 F (37.8 C); pulse 80; blood pressure 120/60; and afebrile for 24 hours. By adding Gentamicin, you are
respirations 18. She has a tender uterine fundus that measures at the covering the spectrum of gram-negative organisms.
umbilicus. Her extremities reveal mild bilateral edema; no erythema or Erythromycin provides good coverage for upper
tenderness. Blood work reveals a white count of 12.2; hematocrit of 34%; respiratory infections. Vancomycin provides good
and normal chemistries. Her urinalysis is positive for blood and coverage for S. aureus and penicillin-resistant gram-
negative for WBCs, leukocyte esterase and nitrites. In addition to positive bacteria. Ciprofloxacin provides excellent
ampicillin, which of the following would be the best antibiotic choice? coverage for gram-negative pathogens, including
Pseudomonas.
A. Erythromycin
B. Gentamicin
C. Doxycycline
D. Vancomycin
E. Ciprofloxacin
Unit 3: Gynecology
Study online at quizlet.com/_2io49q
1. A 12-year-old girl is brought to the office by C. The division of interests based on gender is inappropriate. Children should be
her mother who complains that her encouraged to follow their own interests and desires. The girl has a normal physical
daughter has never been interested in dolls exam; therefore, diagnostic studies are not indicated.
and pretty dresses, but prefers to play with
tools and mechanical things. The mother
also divulges that her brother is gay and is
worried that her daughter will grow up as a
lesbian and be stigmatized. A private
conversation with the girl reveals that she is
starting to show an interest in boys, and
even has a "boyfriend." Examination reveals
a normal pre-pubertal phenotype. Which of
the following is the most appropriate course
of action at this time?
A. Encourage mother to support more
gender-appropriate activities including
dressing like and playing with other girls
B. Refer the mother to a family counselor
C. Reassure the mother that her daughter's
behavior is normal
D. Inform mother that her daughter may
ultimately develop an alternative sexual
lifestyle
E. Have the patient return for a repeat
assessment once she has begun menarche
2. A 16-year-old G0 female presents to the D. Although some patients can be treated with an outpatient regimen, this patient
emergency department with a two-day should be hospitalized for IV treatment, as she has nausea and vomiting so she might
history of abdominal pain, nausea and not be able to tolerate oral medications. While adolescents have no better outcomes
vomiting. She is sexually active with a new from inpatient vs outpatient therapy, each patient should be assessed for compliance.
partner and is not using any form of It is important to treat aggressively in order to prevent the long-term sequelae of
contraception. On examination, her acute salpingitis. You would not wait for culture results before initiating treatment. Her
temperature is 100.2F (37.9C), and she has recent sexual contacts should also be informed (by her and/or with her consent) and
bilateral lower quadrant pain, with slight treated. According to the 2010 CDC treatment guidelines, there are two options for
rebound and guarding. On pelvic parenteral antibiotics covering both gonorrhea and chlamydia. Cefotetan or cefoxitin
examination, she has purulent cervical PLUS doxycycline or clindamycin PLUS gentamicin. For outpatient treatment, the 2010
discharge and cervical motion tenderness. CDC guidelines recommend ceftriaxone, cefoxitin, or other third-generation
Her white count is 14,000/mcL. What is the cephalosporin (such as ceftizoxime or cefotaxime) PLUS doxycycline WITH or
most appropriate next step in the WITHOUT metronidazole. There are alternative oral regimens as well.
management of this patient? http://www.cdc.gov/std/treatment/2010/pid.htm
A. Ectopic pregnancy
B. Appendicitis
C. Acute cystitis
D. Endometriosis
E. Acute salpingitis
4. A 16-year-old girl is brought by her mother to her A. It is not appropriate to discuss the daughter's sexuality with her mother,
primary care physician requesting that her daughter although her mother has the right to know about her daughter's overall
have a gynecological examination. She is fearful that her health as her legal guardian. The daughter should be encouraged to have
daughter is sexually active. A private conversation with an open conversation with her mother, but that this is entirely up to her
the girl reveals that she is sexually active and is on oral discretion and that she will be supported in whatever decision she
contraceptives prescribed by a community clinic. Having ultimately makes about disclosing her sexual activity.
seen what her older sister went through when she
became sexually active, she prefers not to tell her
mother about her sexual activity for fear of severe
punishment. The pelvic examination is normal. Which is
the most appropriate action at this time?
A. Tell the mother that her daughter is healthy
B. Insist to the daughter that she disclose her sexual
activity to her mother
C. Reassure the mother that her daughter's sexual
activity is a normal activity for most girls her age
D. Speak to the mother openly about her daughter's
condition
E. Disclosure of any medical information is forbidden
and a major HIPPA violation
5. A 17-year-old G0 female presents with a three-year C. Chronic pelvic pain is the indication for at least 40% of all gynecologic
history of severe dysmenorrhea shortly after menarche laparoscopies. Endometriosis and adhesions account for more than 90%
at age 14. Her menstrual cycles are regular with heavy of the diagnoses in women with discernible laparoscopic abnormalities,
flow. She has been treated with ibuprofen and oral and laparoscopy is indicated in women thought to have either of these
contraceptives for the last year without significant conditions. Often, adolescents are excluded from laparoscopic evaluation
improvement. She misses 2-3 days of school each month on the basis of their age, but several series show that endometriosis is as
due to her menses. She has never been sexually active. common in adolescents with chronic pelvic pain as in the general
Physical examination is remarkable for Tanner Stage IV population. Therefore, laparoscopic evaluation of chronic pelvic pain in
breasts and pubic hair. Pelvic examination is normal, as adolescents should not be deferred based on age. Laparoscopy can be
is a pelvic ultrasound. Both the patient and her mother both diagnostic and therapeutic in this patient in whom you suspect
are concerned. What is the next best step in the endometriosis. None of the other imaging modalities listed will help in the
management of this patient? further workup of this patient.
A. Sonohysterogram
B. CT scan of the pelvis
C. Diagnostic laparoscopy
D. MRI of the pelvis
E. Hysterosalpingogram
6. A 17-year-old G0 sexually active female presents to the E. The most likely cause of the symptoms and signs in this patient
emergency department with pelvic pain that began 24 hours is infection with a sexually transmitted organism. The most likely
ago. She reports menarche at the age of 15 and coitarche soon organisms are both N. gonorrhoeae and chlamydia, and the
thereafter. She has had four male partners, including her new patient should be treated empirically for both after appropriate
boyfriend of a few weeks. Her blood pressure is 100/60; pulse blood and cervical cultures are obtained. There is no evidence
100; and temperature 102.0F (38.9C). On speculum that adolescents have better outcomes from inpatient therapy.
examination, you note a foul-smelling mucopurulent discharge However, since the patient also has a high fever, inpatient
from her cervical os and she has significant tenderness with admission is recommended for aggressive intravenous antibiotic
manipulation of her uterus. What is the next best step in the therapy in an effort to prevent scarring of her fallopian tubes and
management of this patient? possible future infertility.
A. Pelvic ultrasound
B. Pap test
C. Wet prep
D. Urinalysis
. Testing for chlamydia
8. A 20-year-old G0 college student presents with a one- B. Mucopurulent cervicitis (MPC) is characterized by a mucopurulent
month history of profuse vaginal discharge and mid-cycle exudate visible in the endocervical canal or in an endocervical swab
vaginal spotting. She uses oral contraceptives and she specimen. MPC is typically asymptomatic, but some women have an
thinks her irregular bleeding is due to the pill. She is abnormal discharge or abnormal vaginal bleeding. MPC can be caused
sexually active and has had a new partner within the past by Chlamydia trachomatis or Neisseria gonorrhoeae; however, in most
three months. She reports no fevers or lower abdominal cases neither organism can be isolated. Patients with MPC should be
pain. She has otherwise been healthy. On pelvic tested for both of these organisms. The results of sensitive tests for C.
examination, a thick yellow endocervical discharge is trachomatis or N. gonorrhoeae (e.g. culture or nucleic acid
noted. Saline microscopy reveals multiple white blood amplification tests) should determine the need for treatment, unless the
cells, but no clue cells or trichomonads. Potassium likelihood of infection with either organism is high or the patient is
hydroxide testing is negative. Vaginal pH is 4.0. No cervical unlikely to return for treatment. Antimicrobial therapy should include
motion tenderness or uterine/adnexal tenderness is coverage for both organisms, such as azithromycin or doxycycline for
present. Testing for gonorrhea and chlamydia is chlamydia and a cephalosporin or quinolone for gonorrhea.
performed, but those results will not be available for Uncomplicated cervicitis, as in this patient, would require only 125 mg
several days and the student will be leaving for Europe of Ceftriaxone in a single dose. Ceftriaxone 250 mg is necessary for the
tomorrow. Which of the following is the most appropriate treatment of upper genital tract infection or pelvic inflammatory
treatment for this patient? disease (PID).
A. Age
B. Hypothyroidism
C. Weight
D. Unpredictable periods
E. Her blood pressure
12. A 23-year-old G0 woman with last menstrual period E. Emergency contraceptive pills are not an abortifacient, and they have not
14 days ago presents to the office because she had been shown to cause any teratogenic effect if inadvertently administered
unprotected intercourse the night before. She does during pregnancy. They are more effective the sooner they are taken after
not desire pregnancy at this time and is requesting unprotected intercourse, and it is recommended that they be started within
contraception. She has no medical problems and is 72 hours, and no later than 120 hours. Plan B, the levonorgestrel pills, can
not taking any medications. In addition to offering her be taken in one or two doses and cause few side effects. Emergency
counseling and testing for sexually transmitted contraceptive pills may be used anytime during a woman's cycle, but may
infections, which of the following is the most impact the next cycle, which can be earlier or later with bleeding ranging
appropriate next step in the management of this from light, to normal, to heavy.
patient?
A. Observation
B. Single-agent antibiotics
C. Medical termination of pregnancy plus
antibiotics
D. Uterine evacuation plus antibiotics
E. Laparoscopy plus antibiotics
16. A 23-year-old G2P1 woman with six weeks amenorrhea D. The patient has a septic abortion. She has fever and bleeding
presents with lower abdominal pain and vaginal bleeding. Her with a dilated cervix which are findings seen with septic abortion.
temperature is 102.0F (38.9C) and the cervix is 1 cm dilated. Threatened abortions clinically have vaginal bleeding, a positive
Uterus is eight-week size and tender. There are no adnexal pregnancy test and a cervical os closed or uneffaced. Missed
masses. Urine pregnancy test is positive. What is the most abortions have retention of a nonviable intrauterine pregnancy for
likely diagnosis? an extended period of time (i.e. dead embryo or blighted ovum). A
normal pregnancy would have a closed cervix. Ectopic pregnancy
A. Threatened abortion would likely present with bleeding, abdominal pain, possibly have
B. Missed abortion an adnexal mass, and the cervix would typically be closed.
C. Normal pregnancy
D. Septic abortion
E. Ectopic Pregnancy
17. A 23-year-old nulliparous woman presents with a painful B. This is a typical presentation for folliculitis which can occur with
nodule in her axilla for three days. She is healthy and has no shaving the axillary hair. Paget's disease is a malignant condition of
personal or family history of breast disease. On exam, no the breast that has the appearance of eczema and does not
abnormalities are seen on inspection and no breast mass is typically present in the axillary area. Fibroadenomas are common
palpated. In the axillary area, shaved skin is noted and an and are usually firm, painless and freely movable. A supernumerary
erythematous raised 1 cm lesion is palpated and is slightly nipple is a congenital variation and is typically located in the nipple
tender to touch. What is the most likely diagnosis? line and not tender. A clogged milk duct can be present in the
axillary region, but it is typically present in a woman who is
A. Paget's disease breastfeeding.
B. Folliculitis
C. Fibroadenoma
D. Supernumerary nipple
E. Duct obstruction
18. A 23-year-old woman presents with complaints of a bilateral D. She's young, likely not to be breast cancer.
nipple itchy sensation for six months. There is no nipple
discharge or dry skin. She reports her nipple appears to be
swollen at times and there is an erythematous fine rash. She
had breast implants placed five years ago, but otherwise has
no significant medical problems or surgical history. What is
the most likely cause of her symptoms?
A. Fibroadenoma
B. Breast cancer
C. Rupture of breast implants
D. Chemical irritants
E. Mastitis
19. A 24-year-old G0 woman presents with a one-year history of B. Interstitial cystitis (IC) is a chronic inflammatory condition of the
introital and deep thrust dyspareunia. She has a two-year bladder, which is clinically characterized by recurrent irritative
history of severe dysmenorrhea, despite the use of oral voiding symptoms of urgency and frequency, in the absence of
contraceptives. She also reports significant urinary frequency, objective evidence of another disease that could cause the
urgency, and nocturia. A recent urine culture was negative. symptoms. Pelvic pain is reported by up to 70% of women with IC
She underwent a diagnostic laparoscopy six months ago that and, occasionally, it is the presenting symptom or chief complaint.
showed minimal endometriosis with small implants in the Women may also experience dyspareunia. The specific etiology is
posterior cul de sac only, which were ablated with a CO2 laser. unknown, but IC may have an autoimmune and even hereditary
What is the most likely diagnosis in this patient? component.
A. Acute cystitis
B. Interstitial cystitis
C. Acute urethral syndrome
D. Acute urethritis
E. Salpingitis
20. A 24-year-old G1P1 woman comes to the office E. Oral contraceptives will decrease a woman's risk of developing ovarian
requesting contraception. Her past medical history is and endometrial cancer. The first developed higher dose oral
unremarkable, except for a family history of ovarian contraceptive pills have been linked to a slight increase in breast cancer,
cancer. She denies alcohol, smoking and recreational but not the most recent (current) lower dose pills. Women who use oral
drug use. She is in a monogamous relationship. She contraceptive pills have a slightly higher risk of developing cervical
wants to decrease her risk of gynecological cancer. Of intraepithelial neoplasia, but their risk of developing PID, endometriosis,
the following, what is the best method of contraception benign breast changes and ectopic pregnancy are reduced. Both
for this patient? hypertension and thromboembolic disorders can be a potential side
effect from using oral contraceptive pills. Diaphragms, condoms and
A. Diaphragms intrauterine devices will not lower her risk of ovarian cancer. The
B. Condoms progesterone IUD may decrease a woman's risk for endometrial cancer
C. Copper containing intrauterine device but would not effect her risk for ovarian cancer, and have been associated
D. Progesterone containing intrauterine device with increased ovarian cysts.
E. Combined oral contraceptives
21. A 24-year-old G2P2 woman with a history of two prior D. Approximately 10% of women who have been sterilized regret having
Cesarean deliveries desires a tubal ligation for had the procedure with the strongest predictor of regret being
permanent sterilization. She has two daughters, who undergoing the procedure at a young age. The percentage expressing
are 3 and 1 years old. She is very sure she does not regret was 20% for women less than 30 years old at the time of
desire any more children. She is happily married and is sterilization. For those under age 25, the rate was as high as 40%. The
a stay-at-home-mom. What is the strongest predictor regret rate was also high for women who were not married at the time of
of post-sterilization regret for this patient? their tubal ligation, when tubal ligation was performed less than a year
after delivery, and if there was conflict between the woman and her
A. Not working outside the home partner.
B. Parity
C. Marital status
D. Age
E. Children's gender
22. A 24-year-old woman complains of cyclic mastalgia D. Fibrocystic breast changes are the most common type of benign breast
since the onset of her period at age 12. The symptoms conditions and occur most often during the reproductive years.
have increased over the years but were less Fibrocystic disease is often associated with cyclic mastalgia, possibly
troublesome when she took oral contraceptives a few related to a pronounced hormonal response. Caffeine intake can increase
years ago. Currently, she takes no medications and is the pain associated with fibrocystic breast changes, so recommending
not sexually active. She is a strict vegetarian and eats that she decrease her caffeine intake may be helpful. Pain is not related to
soy products. She does not smoke and she drinks a alcohol intake, her vegetarian diet or age of menarche. There is an
glass of wine three times a week, and several diet colas increased risk of breast cancer when atypia is present.q
every day. Her mother was diagnosed with breast
cancer at age 55. Her breast exam is normal, except for
some mild fibrocystic changes. Which of the following
elements in her history contributes to her increasing
pain?
A. Alcohol intake
B. Vegetarian diet
C. Family history of breast cancer
D. Caffeine intake
E. Age at menarche
23. A 25-year-old G1P0 woman at six weeks gestation D. Medical abortion is associated with higher blood loss than surgical
comes to the office because of undesired pregnancy. abortion. Early in pregnancy (less than 49 days) both medical and surgical
You discuss with her the risks and benefits of surgical procedures can be offered. Mifepristone (an antiprogestin) can be
versus medical abortion using misoprostol and administered, followed by misoprostol (a prostaglandin) to induce uterine
mifepristone. Compared to surgical abortion, which of contractions to expel the products of conception. This approach has
the following is increased in a woman undergoing a proven to be effective (96%) and safe. A surgical termination is required in
medical abortion? the event of failure or excessive blood loss. Medical termination may be
more desirable by some patients since they do not have to undergo a
A. Post abortion pain surgical procedure. It does not affect future fertility. Any termination of
B. Lower failure rate pregnancy, whether medical or surgical, can have psychological sequelae.
C. Long-term psychological sequelae
D. Blood loss
E. Future infertility
24. A 25-year-old G1P1 woman comes to the office due to B. This patient has puerperal mastitis which most often occurs during the
left breast pain and fever. She is breastfeeding her 2 second to fourth week after delivery and the most appropriate next step in
-week-old infant. The symptoms began earlier in the her management is to use ibuprofen in addition to acetaminophen for pain
day and are not relieved by acetaminophen. Her vital relief. She should be encouraged to continue breastfeeding or expressing
signs are: blood pressure 120/60; pulse 64; their milk during treatment. Mastitis is usually treated as an outpatient.
temperature 99.9 F (37.7 C). On exam, she has Patients are treated with oral or IV antibiotics, depending on the severity of
erythema on the upper outer quadrant of the left infection. Cold compresses may reduce inflammation but are not indicated
breast which is tender to touch. There are no palpable in the management of mastitis. Breast binders may increase breast pain. A
masses. In addition to starting oral antibiotics, what is breast ultrasound is not indicated if there is no suspicion of a breast
the most appropriate next step in the management of abscess.
this patient?
A. Discontinue breastfeeding
B. Begin ibuprofen
C. Obtain a breast ultrasound
D. Use a topical antifungal
E. Apply breast binders
25. A 25-year-old G1P1 woman presents with complaints D. Stimulation of the breast during the physical examination may give rise to
of a white, watery nipple discharge for four months. an elevated prolactin level. Accurate prolactin levels are best obtained in
She discontinued breastfeeding six months ago. She the fasting state. If still elevated, then a TSH level and brain MRI would be
has been told in the past she had fibrocystic breast indicated to rule out a pituitary tumor. Post partum women may continue to
changes, but otherwise has no significant medical produce milk for up to two years after cessation of breastfeeding. Although
problems or surgical history. A white nipple discharge pathologic factors such as hypothyroidism, hypothalamic disorders,
is noted on manual expression, but the exam is pituitary disorders (adenomas, empty sella syndrome), chest lesions (breast
otherwise normal. She was then sent for a serum implants, thoracotomy scars, and herpes zoster) and renal failure can
prolactin level which was 45 ng/ml (normal below 40 elevate prolactin levels, a non-significant benign elevation needs to be
ng/ml). What is the most appropriate next step in the ruled out first. A ductogram is usually indicated in patients who have bloody
management of this patient? discharge from a single breast duct.
A. Appendicitis
B. Exacerbation of the endometriosis
C. Ovarian carcinoma
D. Ovarian torsion
E. Ectopic pregnancy
29. A 26-year-old G0 woman returns for a C. Oral contraceptives will be the next best choice for this patient. They provide
follow-up visit regarding endometriosis. negative feedback to the pituitary-hypothalamic axis which stops stimulation of the
She has been using NSAIDs to manage her ovary resulting in ovarian suppression of sex hormone production, such as estrogen.
pelvic pain, but had to miss four days of Since estrogen stimulates endometrial tissue located outside of the endometrium and
work in the last two months. She is sexually uterus, endometriosis can be suppressed by OCPs especially when prescribed in a
active with her husband of two years, continuous fashion (omit the week of placebo pills resulting in no withdrawal bleed).
although it has been more painful recently. GnRH agonists also exert negative feedback, but can be used short term only and
She has regular menstrual cycles and is have more side effects. Danazol is a synthetic androgen used to treat endometriosis,
using condoms for contraception. On but due to its androgenic side effects (weight gain, increased body hair and acne, and
pelvic examination, she has localized adverse affect on blood lipid levels) it is not usually the first choice of treatment.
tenderness in the cul de sac and there are Laparoscopy is indicated in the patient who fails medical treatment and/or is planning
no palpable masses. What is the most pregnancy in the near future. A progesterone intrauterine device might potentially
appropriate next step in the management help alleviate some of her symptoms, but is not the best management for
of this patient? endometriosis.
A. GnRH agonist
B. Danazol
C. Oral contraceptives
D. Laparoscopy and ablation of
endometriosis
E. Progesterone intrauterine device
30. A 26-year-old G0 women returns for a E. Definitive diagnosis is based on exploratory surgery and biopsies, although
follow-up visit regarding suspected endometriosis is usually initially treated based on the clinical presentation. In addition,
endometriosis. She has been using NSAIDs this patient can benefit from laparoscopy, since she has failed the two most common
and oral contraceptive pills to help treatments for endometriosis, NSAIDs and OCPs. There is no imaging study or blood
manage her pelvic pain which has been test that can confirm the diagnosis of endometriosis. CA-125 is non-specific and can be
getting worse. While discussing further elevated in patients with endometriosis, and therefore not helpful.
treatment options, she asks if there is any
test or procedure you can perform to
confirm her diagnosis. Which of the
following would you recommend?
A. CA-125
B. Pelvic ultrasound
C. CT scan of the abdomen and pelvis
D. MRI of the pelvis
E. Diagnostic laparoscopy
31. A 26-year-old A. The patient is most likely infected with herpes. Herpes simplex virus is a highly contagious DNA virus. Initial
G2P2 woman infection is characterized by viral-like symptoms preceding the appearance of vesicular genital lesions. A
presents with a prodrome of burning or irritation may occur before the lesions appear. With primary infection, dysuria due to
new onset of vulvar lesions can cause significant urinary retention requiring catheter drainage. Pain can be a very significant
vulvar burning finding as well. Treatment is centered on care of the local lesions and the symptoms. Sitz baths, perineal care
and irritation. She and topical Xylocaine jellies or creams may be helpful. Anti-viral medications, such as acyclovir, can decrease
is sexually active viral shedding and shorten the course of the outbreak somewhat. These medications can be administered
with a new male topically or orally. Syphilis is a chronic infection caused by the Treponema pallidum bacterium. Transmission is
partner. She is usually by direct contact with an infectious lesion. Early syphilis includes the primary, secondary, and early latent
using oral stages during the first year after infection, while latent syphilis occurs after that and the patient usually has a
contraception for normal physical exam with positive serology. In primary syphilis, a painless papule usually appears at the site of
birth control and inoculation. This then ulcerates and forms the chancre, which is a classic sign of the disease. Left untreated, 25%
did not use a of patients will develop the systemic symptoms of secondary syphilis, which include low-grade fever, malaise,
condom. She headache, generalized lymphadenopathy, rash, anorexia, weight loss, and myalgias. This patient's symptoms are
thought she had a less consistent with syphilis, but she should still be tested for it. Human immunodeficiency virus is an RNA
cold about 10 retrovirus transmitted via sexual contact or sharing intravenous needles. Vulvar burning, irritation or lesions are
days ago. Which not typically noted with this disease, although generalized malaise can be. HIV can present with many different
of the following is signs and symptoms, therefore risk factors should be considered, and testing offered. Trichomonas is a
the most likely protozoan and is transmitted via sexual contact. It typically presents with a non-specific vaginal discharge. It
diagnosis in this does not have a systemic manifestation.
patient?
A. Herpes simplex
virus
B. Primary syphilis
C. Secondary
syphilis
D. Human
immunodeficiency
virus
E. Trichomonas
32. A 26-year-old G2P2 woman presents with urinary urgency and E. Acute cystitis in a healthy, non-pregnant woman is
dysuria for the past three days. She has a history of a urinary tract considered uncomplicated and is very common.
infection once. She is sexually active and uses condoms for Escherichia coli causes 80 to 85 percent of cases. The
contraception. She is otherwise healthy and does not take any other major pathogens are Staphylococcus saprophyticus,
medications or supplements. She does not have fever, chills, flank Klebsiella pneumoniae, Enterococcus faecalis and Proteus
pain or vaginal discharge. Which of the following organisms is the mirabilis. The physician must consider antibiotic resistance
most likely cause of this patient's symptoms? when determining treatment.
A. Enterococcus faecalis
B. Klebsiella pneumoniae
C. Proteus mirabilis
D. Staphylococcus saprophyticus
E. Escherichia coli
33. A 26-year-old lesbian has chronic herpetic lesions on her lip. She is A. Use of a dental dam or a latex condom cut down the
concerned about the affect this will have on her partner when she middle is effective in avoiding infection. Type 1 virus can
performs cunnilingus on her. Physical examination is normal except cause ulcers on the vulva, as it is contagious. Prophylaxis of
for a herpetic lesion on the lip, which has been diagnosed as Herpes the partner with acyclovir is not a recommended strategy
type 1 in the past. Acyclovir is prescribed. Which of the following is to prevent transmission, and petrolatum jelly is not an
the most appropriate advice to this patient? effective barrier.
A. Use a dental dam when having oral sex
B. Provide a prescription for acylovir for her partner to take before
and after oral sex
C. Apply a thin layer of petrolatum jelly over her lips while having
oral sex
D. Inform her that the Herpes virus type 1 is not contagious to the
genitalia
E. Discontinue oral sex
34. A 27-year-old G0 woman presents with a one-year history of C. This patient has typical symptoms of endometriosis,
dysmenorrhea and dyspareunia. Pain, when present, is 7/10 in including dysmenorrhea and dyspareunia. In addition, the
strength and requires that she miss work. She now avoids intercourse nodularity along the back of the uterus along the
and no longer finds it pleasurable. She is otherwise in good health. uterosacral ligaments is suggestive of endometriosis.
Her last menstrual period was 17 days ago and her menses are Chronic pelvic inflammatory disease would not present this
typically 28 days apart. She had chlamydia once, at age 19. Physical far out from a known infection. Adenomyosis is endometrial
examination is notable for mild tenderness on abdominal glands embedded in the wall of the uterus. Endometritis is
examination in the lower quadrants, and bilateral adnexal tenderness an infection of the endometrium. Premenstrual dysphoric
on pelvic examination. Uterus is normal in size and there is disorder (PMDD) is a condition in which a woman has
uterosacral ligament nodularity. What is the most likely diagnosis in severe depressive symptoms, irritability, and tension before
this patient? menstruation.
A. Adenomyosis
B. Chronic pelvic inflammatory disease
C. Endometriosis
D. Endometritis
E. Leiomyoma
35. A 27-year-old G0 woman presents with a three-year history of C. Vestibulodynia (formally vulvar vestibulitis) syndrome consists
dyspareunia. She reports a history of always having painful of a constellation of symptoms and findings limited to the vulvar
intercourse, but she is now unable to tolerate intercourse at all. vestibule, which include severe pain on vestibular touch or
She has avoided sex for the last six months. She describes attempted vaginal entry, tenderness to pressure and erythema
severe pain with penile insertion. On further questioning, she of various degrees. Symptoms often have an abrupt onset and
reports an inability to use tampons because of painful insertion. are described as a sharp, burning and rawness sensation.
She also notes a remote history of frequent yeast infections Women may experience pain with tampon insertion, biking or
while she was on antibiotics for recurrent sinusitis that occurred wearing tight pants, and avoid intercourse because of marked
years ago. Her medical history is unremarkable, and she is not introital dyspareunia. Vestibular findings include exquisite
on medications. Pelvic examination is remarkable for normal tenderness to light touch of variable intensity with or without
appearing external genitalia. Palpation of the vestibule with a Q- focal or diffuse erythematous macules. Often, a primary or
tip elicits marked tenderness and slight erythema. A normal- inciting event cannot be determined. Treatment includes use of
appearing discharge is noted. Saline wet prep shows only a few tricyclic antidepressants to block sympathetic afferent pain
white blood cells, and potassium hydroxide testing is negative. loops, pelvic floor rehabilitation, biofeedback, and topical
Vaginal pH is 4.0. The cervix and uterus are unremarkable. Which anesthetics. Surgery with vestibulectomy is reserved for patients
of the following is the most likely diagnosis in this patient? who do not respond to standard therapies and are unable to
tolerate intercourse.
A. Vaginal cancer
B. Genital herpes infection
C. Vestibulodynia
D. Contact dermatitis
E. Chlamydia infection
36. A 28-year-old G0 woman presents for preoperative counseling. A. Surgery is the gold standard in the diagnosis of
She has a suspected diagnosis of severe endometriosis and has endometriosis, but often is not the initial treatment as suspected
failed conservative medical management with OCPs. Her endometriosis is often managed medically. The role of surgery is
symptoms include severe pelvic pain especially prior to and often to manage the symptoms of endometriosis, often pelvic
during menstruation, and deep dyspareunia. On pelvic pain. As such, surgery may be conservative (laparoscopic
examination, she has uterosacral nodularity and tenderness ablation or excision of implants, excision of endometriomas) or
throughout both adnexa. Ultrasound reveals normal ovaries definitive (total hysterectomy/BSO). In this young nulliparous
bilaterally. Which of the following procedure is the best option patient, definitive surgery is not indicated, and only laser
for this patient? ablation would be recommended. As she has no evidence of
adnexal masses or enlarged ovaries on ultrasound, it is unlikely
A. Laser ablation that ovarian cystectomy would be needed. There is no
B. Ovarian cystectomy indication for salpingectomy.
C. Salpingectomy
D. Bilateral salpingo-oophorectomy
E. Total laparoscopic hysterectomy and bilateral salpingo-
oophorectomy
37. A 29-year-old G0 woman presents due to the inability to C. A patient with a known history of endometriosis, who is
conceive for the last 18 months. She has a known history of unable to conceive and has an otherwise negative workup for
endometriosis, which was diagnosed by laparoscopy three years infertility, benefits from ovarian stimulation with clomiphene
ago. She has pelvic pain, which is controlled with non-steroidal citrate, with or without intrauterine insemination. Waiting another
anti-inflammatory drugs. Her cycles are regular. She is otherwise six months is not appropriate as she has been trying to conceive
in good health and has been married for five years. Her husband for 18 months unsuccessfully. A GnRH agonist is used to control
had a semen analysis, which was normal. She had a pelvic pain in endometriosis patients unresponsive to other
hysterosalpingogram, which showed patent tubes bilaterally. She hormonal treatments. In vitro fertilization and adoption can be
is getting frustrated that she has not yet achieved pregnancy offered if other treatments fail.
and asks to proceed with fertility treatments. What is the most
appropriate next step in the management of this patient?
A. Hyphae
B. Clue cells
C. Trichomonads
D. Lactobacilli
E. Normal epithelial cells
44. A 32-year-old G0 woman with a last menstrual period C. Bacterial vaginosis is the most common cause of vaginitis. The
three weeks ago, presents with a three-month history of a infection arises from a shift in the vaginal flora from hydrogen
malodorous vaginal discharge. She reports no pruritus or peroxide-producing lactobacilli to non-hydrogen peroxide-producing
irritation. She has been sexually active with a new partner lactobacilli, which allows proliferation of anaerobic bacteria. The
for the last four months. Her past medical history is majority of women are asymptomatic; however, patients may
unremarkable. Pelvic examination reveals normal external experience a thin, gray discharge with a characteristic fishy odor that is
genitalia without rash, ulcerations or lesions. Some often worse following menses and intercourse. Modified Amsel criteria
discharge is noted on the perineum. The vagina reveals for diagnosis include three out of four of the following: 1) thin, gray
only a thin, gray homogeneous discharge. The vaginal pH homogenous vaginal discharge; 2) positive whiff test (addition of
is 5.0. A wet prep is shown in the image below. Which of potassium hydroxide releases characteristic amine odor); 3) presence
the following is the most appropriate treatment for this of clue cells on saline microscopy; and 4) elevated vaginal pH >4.5.
patient? Treatment consists of Metronidazole 500 mg orally BID for seven days,
or vaginal Metronidazole 0.75% gel QHS for five days.
A. Ceftriaxone
B. Doxycycline
C. Metronidazole
D. Azithromycin
E. Penicillin
45. A 32-year-old G3P1 woman presents to your office today D. It is estimated that 38% of hepatitis B cases worldwide are acquired
because of exposure to hepatitis B. She had vaginal and from sexual transmission. Post-exposure prophlaxis should be inititated
anal intercourse with a new partner three days ago and as soon as possible but not later than 7 days after blood contact and
did not use condoms. The partner informed her today he within 14 days after sexual exposure. In individuals who are
was recently diagnosed with acute hepatitis B acquired unvaccinated but exposed to persons who are HBsAG positive,
from intravenous drug use and needle sharing. She has no recommendations are to receive one dose of HBIG (Hepatitis B
prior history of hepatitis B infection and has not been Immune Globulin) and the HBV (Hepatitis B Vaccine Series). If the
vaccinated. She is currently asymptomatic and her source is HBsAG negative or unknown status, then only the HBV series
examination is normal. Her urine pregnancy test is is used. If the exposed individual has been vaccinated and is a
negative. What is the next best step in the management of responder then no further treatment is necessary. If the exposed
this patient? individual is vaccinated and a non-responder, then HBIG plus HBV or
HBIG times two doses is used. Because the incubation period for the
A. Check AST, ALT, and HBsAg virus is six weeks to six months, checking liver function and
B. Administer HBIG one dose immunologic status at this time is not indicated.`
C. Administer HBIG two doses
D. Administer HBIG and start hepatitis B vaccine series
E. Administer hepatitis B vaccine series only
46. A 32-year-old G3P2 woman with a last menstrual D. Irritable bowel syndrome (IBS) is a common functional bowel disorder of
period two weeks ago presents with a six-month uncertain etiology. It is characterized by a chronic, relapsing pattern of
history of abdominal pain. She has noncyclic abdominal and pelvic pain, and bowel dysfunction with constipation or
intermittent pain, which she describes as crampy diarrhea. IBS is one of the most common disorders associated with chronic
and diffuse across the lower abdomen. Her pain pelvic pain. IBS appears to occur more commonly in women with chronic pelvic
is typically relieved with defecation and is pain than in the general population. Diagnosis is based on the Rome II Criteria
associated with loose, watery stools. Onset of the for IBS, which includes at least 12 weeks (need not be consecutive) in the
symptoms is associated with a change in stool preceding 12 months of abdominal discomfort or pain that has two of three
frequency from once daily to multiple times features: 1) relief with defecation; 2) onset associated with a change in frequency
daily. She also experiences bloating and of stool; or 3) onset associated with a change in stool form or appearance. The
abdominal distention several times a week. Her patient's history does not support pelvic adhesions, and diverticulosis (although
medical history is significant for chronic very common) typically may be asymptomatic unless inflammation/infection
migraines and she denies previous surgery. Her develops. In this case, the symptoms for IBS may be indistinguishable from
gynecological history is unremarkable. Her diverticulitis or severe diverticular disease. Although severe endometriosis may
abdominal examination is notable for mild affect the lower bowel with constricting and invasive implants, the lack of any
tenderness to palpation in the left lower gynecologic/menstrual symptoms and the normal pelvic examination essentially
quadrant, and her pelvic examination is normal. excludes this diagnosis. The lack of recent antibiotic exposure essentially rules
What is the most likely diagnosis in this patient? out the diagnosis of C. difficile.
A. Pelvic adhesions
B. Diverticulosis
C. Endometriosis
D. Irritable bowel syndrome
E. C. difficile colitis
47. A 32-year-old G3P3 woman comes to the office E. Both vasectomy and tubal ligation are 99.8% effective. Vasectomies are
to discuss permanent sterilization. She has a performed as an outpatient procedure under local anesthesia, while tubal
history of hypertension and asthma (on ligations are typically performed in the operating room under regional or
corticosteroids). She has been married for 10 general anesthesia; therefore carrying slightly more risk to the woman, assuming
years. Vital signs show: blood pressure 140/90; both are healthy. She is morbidly obese, so the risk of anesthesia and surgery
weight 280 pounds; height 5 feet 9 inches; and are increased. In addition, she has chronic medical problems that put her at
BMI 41.4kg/m2. You discuss with her risks and increased risk of having complications from surgery.
benefits of contraception. Which of the following
would be the best form of permanent sterilization
to recommend for this patient?
A. Endometriosis
B. Endometritis
C. Adenomyosis
D. Pelvic congestion
E. Pelvic floor relaxation
49. A 33-year-old G3P3 woman presents to the C. The patient is most likely has candida vaginalis. Clinically women have itching and
office complaining of a new onset vaginal thick white cottage cheese like discharge. They may also have burning with urination
discharge of four days duration. The and pain during intercourse. Herpes simplex viral infections are characterized by viral
discharge is thick and white. She has noted like symptoms preceding the appearance of vesicular genital lesions. A prodrome of
painful intercourse and itching since the burning or irritation may occur before the lesions appear. With primary infection,
discharge began. Her vital signs are: blood dysuria due to vulvar lesions can cause significant urinary retention requiring catheter
pressure 120/76 and pulse 78. The pelvic drainage. Pain can be a very significant finding as well. Syphilis is a chronic infection
examination reveals excoriations on the caused by the Treponema pallidum bacterium. Transmission is usually by direct
perineum, thick white discharge, and is contact with an infectious lesion. Early syphilis includes the primary, secondary, and
otherwise non-contributory. What is the early latent stages during the first year after infection, while latent syphilis occurs after
most likely diagnosis in this patient? that and the patient usually has a normal physical exam with positive serology. In
primary syphilis, a painless papule usually appears at the site of inoculation. This then
A. Herpes simplex virus ulcerates and forms the chancre, which is a classic sign of the disease. Left untreated,
B. Primary syphilis 25% of patients will develop the systemic symptoms of secondary syphilis, which
C. Candida vaginalis include low-grade fever, malaise, headache, generalized lymphadenopathy, rash,
D. Bacterial vaginosis anorexia, weight loss, and myalgias. Bacterial vaginosis is due to an overgrowth of
E. Trichomonas anaerobic bacteria and characterized by a grayish / opaque foul-smelling discharge.
Trichomonas is a protozoan and is transmitted via sexual contact. It typically presents
with a non-specific yellow or greenish vaginal discharge. It does not have a systemic
manifestation.
50. A 35-year-old G1P0 woman with last menstrual period one week D. Most published evidence suggests a significant association of
ago presents with an eight-month history of pelvic pain. She physical and sexual abuse with various chronic pain disorders.
reports regular menstrual cycles with moderate flow and The arguments with the new partner allude to possible abuse.
dysmenorrhea, relieved with ibuprofen. She describes her pain Studies have found that 40-50% of women with chronic pelvic
as a deep, achy sensation with frequent sharp exacerbations. pain have a history of abuse. Whether abuse (physical or sexual)
She has not been sexually active for the last several months specifically causes chronic pelvic pain is not clear, nor is a
because of dyspareunia and some arguments with her new mechanism established by which abuse might lead to the
partner of one year. She has no history of sexually transmitted development of chronic pelvic pain. Women with a history of
infections. Her medical history is significant for irritable bowel sexual abuse and high somatization scores have been found to
syndrome, managed with a fiber supplement. She is a business be more likely to have non-somatic pelvic pain, suggesting the
executive. She has smoked one pack of cigarettes a day since link between abuse and chronic pelvic pain may be psychologic
age 25, and drinks a glass of wine three times a week. She tries or neurologic. However, studies also suggest that trauma or
to exercise regularly by running three to four times a week. This abuse may also result in biophysical changes, by literally
new pain is distinctly different from her IBS symptoms. Which of heightening a person's physical sensitivity to pain. While smoking
the following risk factors can contribute to increased incidence can be associated with dysmenorrhea, she has been smoking for
of pelvic pain in this patient? 10 years and her symptoms are recent onset.
A. Alcohol use
B. Smoking habit
C. Occupation
D. New partner
E. Age
51. A 35-year-old G3P3 woman comes to the office because she E. The levonorgestrel intrauterine device has lower failure rates
desires contraception. Her past medical history is significant for within the first year of use than does the copper containing
Wilson's disease, chronic hypertension and anemia secondary to intrauterine device. It causes more disruption in menstrual
menorrhagia. She is currently on no medications. Her vital signs bleeding, especially during the first few months of use, although
reveal a blood pressure of 144/96. Which of the following the overall volume of bleeding is decreased long-term and
contraceptives is the best option for this patient? many women become amenorrheic. The levonorgestrel
intrauterine device is protective against endometrial cancer due
A. Progestin-only pill to release of progestin in the endometrial cavity. She is not a
B. Low dose combination contraceptive candidate for oral contraceptive pills because of her poorly
C. Continuous oral contraceptive controlled chronic hypertension. The progestin-only pills have a
D. Copper containing intrauterine device much higher failure rate than the progesterone intrauterine
E. Levonorgestrel intrauterine device device. She is not a candidate for the copper-containing
intrauterine device because of her history of Wilson's disease.
52. A 35-year-old G3P3 woman requests contraception. Her E. Ideal candidates for progestin-only pills include women who
youngest child is seven years old. Her periods have been regular have contraindications to using combined oral contraceptives
since she discontinued breastfeeding five years ago. Her past (estrogen and progestin containing). Contraindications to
medical history includes depression that is controlled with estrogen include a history of thromboembolic disease, women
antidepressants, and a history of deep venous thrombosis. She who are lactating, women over age 35 who smoke or women
denies smoking or alcohol use. In the past, oral contraceptive who develop severe nausea with combined oral contraceptive
pills have caused her to have severe gastrointestinal upset. What pills. Progestins should be used with caution in women with a
in her history makes her an ideal candidate for progestin-only history of depression.
pills?
A. Depression
B. Smoking history
C. Severe nausea on combined oral contraceptives
D. Lactation history
E. Deep venous thrombosis
53. A 36-year-old G0 woman presents to the emergency D. Although salpingitis is most often caused by sexually
department accompanied by her female partner. The patient transmitted agents such as gonorrhea and chlamydia, any
notes severe abdominal pain. She states that this pain began 2- ascending infection from the genitourinary tract or gastrointestinal
3 days ago and was associated with diarrhea as well as some tract can be causative. The infection is polymicrobial consisting of
nausea. It has gotten progressively worse and she has now aerobic and anaerobic organisms such as E. coli, Klebsiella, G.
developed a fever. Neither her partner, nor other close vaginalis, Prevotella, Group B streptococcus and/or enterococcus.
contacts, report any type of viral illness. She had her appendix Although diverticulitis and gastroenteritis should be part of the
removed as a teenager. On examination, her temperature is differential diagnosis initially, the specific findings on examination
102.0F (38.9C), her abdomen is tender with mild guarding and and ultrasound are more suggestive of bilateral tubo-ovarian
rebound, and she has an elevated white count. On pelvic abscesses. Even though this patient does not have the typical risk
examination, she is exquisitely tender, such that you cannot factors for salpingitis, the diagnosis should be considered and
complete the examination. Pelvic ultrasound demonstrates explained to the patient in a sensitive and respectful manner. The
bilateral 3-4 cm complex masses. What is the most likely patient should also be questioned separate from her partner
underlying pathogenesis of her illness? regarding the possibility of other sexual contacts.
A. Diverticulitis
B. Gastroenteritis
C. Reactivation of an old infection
D. Ascending infection
E. Pyelonephritis
54. A 36-year-old G2P0 woman at 11 weeks gestational age C. Manual vacuum aspiration is more than 99% effective in early
requests a surgical termination of pregnancy. She had a pregnancy (less than eight weeks). Age, parity and medical
manual vacuum aspiration last year and would like to undergo illnesses are not contraindications for manual vacuum aspiration.
the same procedure again. She has chronic hypertension and Although the risk of Asherman's syndrome increases with each
diabetes well controlled on medications. Vital signs reveal a subsequent pregnancy termination, this patient may still undergo
blood pressure of 120/80 and fasting blood glucose of 100. surgical termination as long as she understands risks and benefits.
Which of the following is a contraindication for manual vacuum Complications of pregnancy termination increase with increasing
aspiration of this patient? gestational age.
A. Age
B. Parity
C. Gestational age
D. Chronic hypertension
E. Diabetes
55. A 36-year-old G2P2 woman presents with irregular vaginal A. The patient should be reassured since initially after Depo-
bleeding. Six weeks ago, she had her first Depo-Provera Provera injection there may be unpredictable bleeding. This
injection and now she has unpredictable bleeding. She is usually resolves in 2-3 months. In general, after one year of using
concerned by these symptoms. She has a history of Depo-Provera, nearly 50% of users have amenorrhea.
hypertension but is currently on no medications. Vital signs
reveal: blood pressure 130/90; weight 188 pounds; height 5
feet 5 inches; BMI 31.4kg/m2. Which of the following is the
most appropriate next step in the management of this patient?
A. Reassurance
B. Begin oral contraceptives
C. Begin estrogen
D. Insert etonogestrel implant (Implanon)
E. Perform an endometrial biopsy
56. A 37-year-old G0 woman presents C. Two serotypes of HSV have been identified: HSV-1 and HSV-2. Most cases of recurrent
with a one-week history of a mildly genital herpes are caused by HSV-2. Up to 30% of first-episode cases of genital herpes are
painful vulvar ulcer. She reports no caused by HSV-1, but recurrences are much less frequent for genital HSV-1 infection than
fevers, malaise or other systemic genital HSV-2 infection. Genital HSV infections are classified as initial primary, initial nonprimary,
symptoms. She recently started recurrent and asymptomatic. Initial, or first-episode primary genital herpes is a true primary
use of a topical steroid ointment infection (i.e. no history of previous genital herpetic lesions, and seronegative for HSV
for a vulvar contact dermatitis. She antibodies). Systemic symptoms of a primary infection include fever, headache, malaise and
is married and has no prior history myalgias, and usually precede the onset of genital lesions. Vulvar lesions begin as tender
of sexually transmitted infections. grouped vesicles that progress into exquisitely tender, superficial, small ulcerations on an
She reports no travel outside the erythematous base. Initial, nonprimary genital herpes is the first recognized episode of genital
United States by her husband or herpes in individuals who are seropositive for HSV antibodies. Prior HSV-1 infection confers
herself. Her last Pap smear, six partial immunity to HSV-2 infection and thereby lessens the severity of type 2 infection. The
months ago, was normal. A vulvar severity and duration of symptoms are intermediate between primary and recurrent disease,
herpes culture later returns with individuals experiencing less pain, fewer lesions, more rapid resolution of clinical lesions
positive for herpes simplex virus and shorter duration of viral shedding. Systemic symptoms are rare. Recurrent episodes involve
type 2. A Rapid Plasma Reagin reactivation of latent genital infection, most commonly with HSV-2, and are marked by episodic
(RPR) is nonreactive, and HIV prodromal symptoms and outbreaks of lesions at varying intervals and of variable severity.
testing is negative. Which of the Clinical diagnosis of genital herpes should be confirmed by viral culture, antigen detection or
following is the most likely serologic tests. Treatment consists of antiviral therapy with acyclovir, famciclovir or valacyclovir.
diagnosis in this patient?
A. Endometrioma
B. Hemorrhagic cyst
C. Ovarian carcinoma
D. Mature teratoma
E. Polycystic ovaries
59. A 42-year-old G2P2 woman presents with a two-week B. Vulvovaginal candidiasis (VVC) usually is caused by C. albicans, but is
history of a thick, curdish white vaginal discharge and occasionally caused by other Candida species or yeasts. Typical
pruritus. She has not tried any over-the-counter symptoms include pruritus and vaginal discharge. Other symptoms
medications. She is currently single and not sexually include vaginal soreness, vulvar burning, dyspareunia and external
active. Her medical history is remarkable for recent dysuria. None of these symptoms are specific for VVC. The diagnosis is
antibiotic use for bronchitis. On pelvic examination, the suggested clinically by vulvovaginal pruritus and erythema with or
external genitalia show marked erythema with satellite without associated vaginal discharge. The diagnosis can be made in a
lesions. The vagina appears erythematous and woman who has signs and symptoms of vaginitis when either: a) a wet
edematous with a thick white discharge. The cervix preparation (saline or 10% KOH) or Gram stain of vaginal discharge
appears normal and the remainder of the exam is demonstrates yeasts or pseudohyphae; or b) a vaginal culture or other
unremarkable except for mild vaginal wall tenderness. test yields a positive result for a yeast species. Microscopy may be
Vaginal pH is 4.0. Saline wet prep reveals multiple white negative in up to fifty percent of confirmed cases. Treatment for
blood cells, but no clue cells or trichomonads. Potassium uncomplicated VVC consists of short-course topical Azole formulations
hydroxide prep shows the organisms. Which of the (1-3 days), which results in relief of symptoms and negative cultures in
following is the most appropriate treatment for this 80%-90% of patients who complete therapy.
patient?
A. Clindamycin
B. Azole cream
C. Metronidazole
D. Doxycycline
E. Ciprofloxacin
60. A 42-year-old G2P2 woman presents with chronic pelvic pain of C. The patient most likely has pelvic adhesive disease as a
two years duration. She describes the pain as constant ever since result of her prior hysterectomy. The development of a
she underwent a laparoscopic-assisted vaginal hysterectomy for postoperative pelvic infection likely has contributed to the
menorrhagia and dysmenorrhea. She did not have any evidence of further development of pelvic adhesions involving the tubes
endometriosis or obvious ovarian pathology at the time of surgery. and ovaries that were retained. Although she did have a pelvic
During the postoperative period, she developed pelvic pain and infection, it is unlikely that her pain resulted from classic PID
fever, and was diagnosed with a pelvic/vaginal cuff abscess that since her adnexa appeared normal at the time of the
was treated with antibiotics and percutaneous drainage. Her pain hysterectomy. It is likely that her tubes and ovaries were
persisted in the subsequent months. Follow-up imaging over the affected by the postoperative infection, and as a result she
next two years indicated transient ovarian cysts. Her abdominal may develop chronic pain from the adhesive disease and tubal
examination is notable for mild-moderate tenderness across the damage from that acute infection. The cyclical nature of the
lower quadrants, and her pelvic examination is notable for severe ovarian cyst essentially rules out ovarian cancer. Ovarian
tenderness at the vaginal cuff with fullness noted in the midline. remnant syndrome occurs following surgical removal of the
Which of the following is the most likely diagnosis in this patient? ovaries, with subsequent development of cyclical pain due to
ovarian tissue that was left behind inadvertently.
A. Endometriosis
B. Pelvic inflammatory disease
C. Pelvic adhesive disease
D. Ovarian remnant syndrome
E. Ovarian cancer
61. A 42-year-old G3P3 woman comes to the office after noticing a D. Given her positive family hx, can assume that the
breast mass while performing a breast self-exam. She is in good mammogram might be a false negative. she is >25yo, so go for
health and has normal menstrual cycles. Family history is the FNA.
significant for multiple first and second-degree relatives having
breast cancer. Physical exam reveals a 2 cm dominant breast mass.
The remainder of the exam is normal. A mammogram obtained
today shows no abnormalities. What is the most appropriate next
step in the management of this patient?
A. Reassurance and observation
B. Obtain genetic testing for BRCA1 and BRCA2
C. MRI of the breast
D. Fine needle aspiration
E. Repeat mammogram in two months
62. A 42-year-old G3P3 woman comes to the office after noticing a D. A specimen obtained on fine-needle aspiration (FNA) is
breast mass while performing a breast self-exam. She is in good examined both histologically and cytologically. An excisional
health and has normal menstrual cycles. Physical exam is biopsy should be performed when the results are negative,
significant for a 2 cm dominant breast mass. The remainder of the due to the possibility of a false-negative result. FNA can,
exam is normal. A mammogram obtained today shows no however, prevent the need for other diagnostic testing and is
abnormalities. A fine needle aspiration was negative, and the mass the appropriate first step in the evaluation of a palpable
persisted. What is the most appropriate next step in the breast mass. Breast ultrasound can be used to distinguish
management of this patient? between a cyst and a solid mass. Fine needle aspiration under
ultrasound guidance can help distinguish a fibroadenoma from
A. Reassurance and observation a cyst and exclude cancer in certain situations. A normal
B. Obtain an MRI of the chest mammogram does not rule out breast cancer and there is no
C. Breast ultrasound need to repeat it in two months. There are no indications for
D. Perform an excisional biopsy obtaining an MRI of the chest in the initial diagnosis of this
E. Repeat mammogram in two months patient.
63. A 45-year-old G2P2 woman underwent B. Nerve entrapment syndrome is a commonly misdiagnosed neuropathy that can
an abdominal hysterectomy for a large complicate pelvic surgical procedures performed through a low transverse incision. The
fibroid uterus via a low transverse skin nerves at risk are the iliohypogastric nerve (T-12, L-1) and the ilioinguinal (T-12, L-1) nerve.
incision. Her postoperative course was These two nerves exit the spinal column at the 12th vertebral body and pass laterally
significant for new onset right lower through the psoas muscle before piercing the transversus abdominus muscle to the
quadrant pain and numbness, radiating anterior abdominal wall. Once at the anterior superior iliac spine, the iliohypogastric
into the right inguinal area and medial nerve courses medially between the internal and external oblique muscles, becoming
thigh. Her pain was exacerbated by cutaneous 1 cm superior to the superficial inguinal ring. The iliohypogastric nerve
adduction of her right thigh. On provides cutaneous sensation to the groin and the skin overlying the pubis. The
abdominal examination, there is a well- ilioinguinal nerve follows a similar, although slightly lower, course as the iliohypogastric
healed low transverse incision. Her pain is nerve where it provides cutaneous sensation to the groin, symphysis, labium and upper
reproduced with adduction of the right inner thigh. These nerves may become susceptible to injury when a low transverse
thigh. There is decreased sensation to incision is extended beyond the lateral border of the rectus abdominus muscle, into the
light touch and pinprick over the right internal oblique muscle. Symptoms are attributed to suture incorporation of the nerve
inguinal area and right medial thigh. during fascial closure, direct nerve trauma with subsequent neuroma formation, or
Patellar reflexes are 2+ and symmetric. neural constriction due to normal scarring and healing. Damage to the obturator nerve,
Entrapment of which of the following which can occur during lymph node dissection would result in the inability of the patient
nerves is the most likely cause of her to adduct the thigh.
pain?
A. Obturator nerve
B. Ilioinguinal nerve
C. Lateral femoral cutaneous nerve
D. Femoral nerve
E. Iliohypogastric nerve
64. A 46-year-old female is scheduled to A. The external genitalia, specifically the clitoris, are essential organs involved in the
undergo a total laparoscopic arousal component of the sexual response cycle, which consists of desire, arousal,
hysterectomy for menorrhagia. She orgasm, and resolution. Hormones such as androgen and estrogen (produced by the
comes into your office to discuss the ovaries) are key to desire, while genital mechanisms such as clitoral, labial, and vaginal
effects a hysterectomy will have on her engorgement are key to arousal. With arousal and adequate sensory stimulation,
sex life. She is concerned about how a orgasm ultimately may occur consisting of repeated motor contractions of the pelvic
hysterectomy will affect her floor including uterine and vaginal smooth muscle contractions.
"womanhood" and read in a woman's
magazine that the cervix, as well as the
uterus, is necessary for orgasm. Which of
the following organs is most responsible
for sexual arousal?
A. Vulva
B. Cervix
C. Uterus
D. Ovary
E. All of the above
65. A 48-year-old G0 comes to the office for a health maintenance B. A repeat ultrasound is the most appropriate next step, as this
examination. She is healthy and not taking any medications. She is most likely a hemorrhagic cyst which will resolve on its own.
has no history of abnormal Pap tests or sexually transmitted Oral contraceptives are contraindicated in this patient, as she is
infections. She is not currently sexually active. Her menstrual older than 35 and smokes. A CT scan of the pelvis will not add
cycles are normal and her last cycle was three weeks ago. She any more information. Needle aspiration is not the standard of
smokes one pack of cigarettes per day. Her mother was care in this asymptomatic premenopausal patient. There is no
diagnosed with endometriosis and had a hysterectomy and indication to proceed with a TAH/BSO.
removal of the ovaries at age 38. She is 5 feet 4 inches tall and
weighs 130 pounds. On pelvic examination, the patient has a
palpable left adnexal mass. An ultrasound was obtained, which
showed a 4 cm complex left ovarian cyst and a 2 cm simple cyst
on the right ovary. What is the most appropriate next step in the
management of this patient?
A. Oral contraceptives
B. Repeat ultrasound in two months
C. CT scan of the abdomen and pelvis
D. Needle aspiration of the cyst
E. Abdominal hysterectomy and bilateral salpingo-oophorectomy
(TAH/BSO)
66. A 48-year-old G0 woman presents to the office for preoperative B. Risk factors for the development of pelvic organ prolapse
counseling. She has severe endometriosis that has failed medical are increasing parity, increasing age, obesity, some connective
management, and she is planning to undergo a robotic total tissue disorders (Ehlers-Danlos syndrome), and chronic
hysterectomy and salpingo-oophorectomy. She is concerned constipation. Vaginal delivery is associated with a higher risk of
about developing a "dropped bladder" following her surgery, POP than Cesarean delivery. It is unclear whether occupations
since both her mother and aunt have undergone surgery for this that require heavy lifting increase the risk of POP. Women with a
condition. She reports no urinary incontinence or other urinary or family history of POP have up to a 2.5 fold increase in prolapse.
bowel symptoms. She is in good health and exercises with Although hysterectomy is associated with an increased risk of
running and weight lifting. Pelvic examination reveals a well- apical prolapse, studies show mixed results on the role of
estrogenized vagina, a normal nulliparous cervix, anteverted hysterectomy in the development of prolapse. The risk of future
uterus, and mildly tender adnexa without masses. Which of the prolapse may be highest when hysterectomy is performed in
following is likely to increase her risk of subsequent women with existing prolapse, while the risk in women with
development of pelvic organ prolapse? normal pelvic support is less clear.
A. Age
B. Family History
C. Endometriosis
D. Exercising
E. Hysterectomy
67. A 48-year-old G4P4 woman with last menstrual period four weeks ago C. It is estimated that chronic pelvic pain is the
presents with a one-year history of non-cyclical pelvic pain, dysmenorrhea principal preoperative indication for 10-12% of
and dyspareunia. She has a past history of endometriosis, diagnosed 10 hysterectomies. Since the patient had a tubal
years ago by laparoscopy. She had previously been on oral contraceptives ligation and does not desire any more children, the
for birth control and menstrual cycle regulation, but elected for permanent best option is removal of ovaries with or without a
laparoscopic sterilization 14 months ago. Minimal endometriosis was noted at hysterectomy. Repeat laparoscopy with treatment
the time of laparoscopy. She now has recurrent symptoms and desires of endometriosis and adhesions can be helpful;
definitive treatment. Which of the following is the most appropriate surgical however, the patient will continue to be at
option for this patient?A 48-year-old G4P4 woman with last menstrual increased risk of recurrent disease. An endometrial
period four weeks ago presents with a one-year history of non-cyclical ablation or wedge resection of ovaries alone would
pelvic pain, dysmenorrhea and dyspareunia. She has a past history of not be very helpful in the setting of non-cyclical
endometriosis, diagnosed 10 years ago by laparoscopy. She had previously pain.
been on oral contraceptives for birth control and menstrual cycle regulation,
but elected for permanent laparoscopic sterilization 14 months ago. Minimal
endometriosis was noted at the time of laparoscopy. She now has recurrent
symptoms and desires definitive treatment. Which of the following is the
most appropriate surgical option for this patient?
A. Cystocele repair
B. Pelvic ultrasound
C. Total hysterectomy
D. Observation
E. Topical estrogen
73. A 57-year-old G2P2 is seen for a routine visit. She B. The patient is not on hormone replacement therapy. With decreased
states she and her 75-year-old husband stopped estrogen production after menopause, the vaginal mucosa and other
having sexual intercourse three years ago when he estrogen-dependent tissues can become atrophic. Topical estrogen therapy
had an operation for prostate cancer. Menopause can restore the integrity of the vaginal epithelium, as well as the support
occurred at age 50 and she denies taking tissues around the vagina. Long-term use may require addition of a progestin
hormones. Her husband now wishes to resume due to potential systemic absorption and effect on the endometrium.
intercourse and is able to get an erection with Dyspareunia (pain with intercourse) can often be improved with the use of
sildenafil (Viagra). Attempts at intercourse have estrogen cream used vaginally. Water based lubricants may be helpful, but
been unsuccessful due to the pain she experiences petroleum jelly is contraindicated because it can cause irritation of the vaginal
when insertion is attempted. Examination is normal mucosa. This patient does not have any other menopausal symptoms that
except for a narrowed vagina with atrophic would be treated by oral combination HRT. Oral progesterone may help to
mucosa. Which of the following is the most decrease hot flushes, but progesterone cream would not alleviate vaginal
appropriate recommendation at this time? atrophy.
A. Progesterone cream
B. Estrogen cream
C. Oral combined hormone therapy
D. Petroleum jelly
E. Vaginal dilators
74. A 57-year-old G2P2 woman presents with a six- C. This patient has urge incontinence, which is caused by overactivity of the
month history of urinary incontinence, urgency, detrusor muscle resulting in uninhibited contractions, which cause an increase
and nocturia. She describes the amount of urine in the bladder pressure over urethral pressure resulting in urine leakage. Stress
loss as large and lasting for several seconds. The incontinence is caused by an increase in intra-abdominal pressure (coughing,
urine loss occurs when she is standing or sitting sneezing) when the patient is in the upright position. This increase in pressure
and is not associated with any specific activity. A is transmitted to the bladder that then rises above the intra-urethral pressure
post-void residual is 50cc. What is the most likely causing urine loss. Associated structural defects are cystocele or urethrocele.
cause of this patient's symptoms? Overflow incontinence is associated with symptoms of pressure, fullness, and
frequency, and is usually a small amount of continuous leaking. It is not
A. Stress incontinence associated with any positional changes or associated events. Mixed
B. Overflow incontinence incontinence occurs when increased intra-abdominal pressure causes the
C. Urge incontinence urethral-vesical junction to descend causing the detrusor muscle to contract.
D. Mixed incontinence A vesicovaginal fistula typically results in continuous loss of urine.
E. Vesicovaginal fistula
75. A 60-year-old G2P2 woman presents with complaints of urinary B. The patient has the diagnosis of detrusor instability. The
frequency and urge incontinence. Past medical history is parasympathetic system is involved in bladder emptying and
unremarkable. She is on no medications. Pelvic examination reveals acetylcholine is the transmitter that stimulates the bladder to
no evidence of pelvic relaxation. Post void residual is normal. Urine contract through muscarinic receptors. Thus, anticholinergics
analysis is negative. A cystometrogram reveals uninhibited detrusor are the mainstay of pharmacologic treatment. Oxybutynin is
contractions upon filling. Which of the following is the best one example. Although the tricyclic antidepressant,
treatment for this patient? amitriptyline, has anticholinergic properties, its side effects
do not make it an ideal choice. Vaginal estrogen has been
A. Amitriptyline shown to help with urgency, but not urge incontinence.
B. Oxybutynin Pseudoephedrine has been shown to have alpha-adrenergic
C. Topical (vaginal) estrogen properties and may improve urethral tone in the treatment of
D. Pseudoephedrine stress incontinence. Kegel exercises or pelvic muscle training
E. Kegel exercises are used to strengthen the pelvic floor and decrease urethral
hypermobility for the treatment of stress urinary
incontinence.
76. A 60-year-old G4P4 woman presents with a two-year history of A. Genuine stress incontinence (GSI) is the loss of urine due
urine leakage with activity such as coughing, sneezing and lifting. to increased intra-abdominal pressure in the absence of a
Her past medical history is significant for vaginal deliveries of detrusor contraction. The majority of GSI is due to urethral
infants over 9 pounds. She had a previous abdominal hysterectomy hypermobility (straining Q-tip angle >30 degrees from
and bilateral salpingo-oophorectomy for uterine fibroids. She is on horizon). Some (<10%) of GSI is due to intrinsic sphincteric
vaginal estrogen for atrophic vaginitis. Physical examination reveals deficiency (ISD) of the urethra. Patients can have both
no anterior, apical or posterior wall vaginal prolapse. The vagina is hypermobility and ISD. Retropubic urethropexy such as
well-estrogenized. Post-void residual is normal. Q-tip test shows a tension-free vaginal tape and other sling procedures have
straining angle of 60 degrees from the horizontal. Cough stress test the best five-year success rates for patients with GSI due to
shows leakage of urine synchronous with the cough. hypermobility. Needle suspensions and anterior repairs have
Cystometrogram reveals the absence of detrusor instability. The lower five-year success rates for GSI. Urethral bulking
patient failed pelvic muscle exercises and is not interested in an procedures are best for patients with ISD, but with little to no
incontinence pessary. Which of the following is the best surgical mobility of the urethra. Colpocleisis is one option to treat
option for this patient? uterine prolapse, and is not indicated for urinary
incontinence.
A. Retropubic urethropexy
B. Needle suspension
C. Anterior repair
D. Urethral bulking procedure
E. Colpocleisis
77. A 62-year-old G5P5 woman presents with a seven-month history of A. Given the patient's age, nonspecific abdomino-pelvic
pelvic pain and pressure, as well as abdominal distention and symptoms, recent postmenopausal bleeding episode and
bloating. She experiences occasional constipation, but no melena family history of ovarian cancer, a transvaginal ultrasound is
or hematochezia. She also has mild to moderate urinary frequency the next best step as it is more sensitive than CT for
without dysuria, hematuria or flank pain. Her medical history is evaluation of the uterus and adnexa. Colonoscopy is useful
significant for hypertension and obesity. She went through for colorectal cancer screening, as well as evaluation of the
menopause 12 years ago and has never been on hormone therapy. patient's gastrointestinal symptoms, but would not provide
She reports one episode of light vaginal bleeding several months information regarding pelvic anatomy. Diagnostic
ago. Her family history is significant for postmenopausal ovarian laparoscopy would be a more invasive procedure that could
cancer in her mother and maternal aunt, but is otherwise negative be performed as indicated, after these other diagnostic
for breast, endometrial or colon cancer. Pelvic examination is studies. Hysteroscopy might be useful based on the
remarkable for vaginal atrophy, cervical stenosis and difficult ultrasound results, since it might be difficult to perform an
uterine and adnexal assessment due to her body habitus. What is endometrial biopsy in the office.
the most appropriate next step in the management of this patient?
A. Transvaginal ultrasound
B. CT scan of the abdomen and pelvis
C. Colonoscopy
D. Hysteroscopy
E. Diagnostic laparoscopy
78. A 64-year-old G2P2 woman presents with a 12-month B. Lichen sclerosus is a chronic inflammatory skin condition that most
history of severe vulvar pruritus. She has applied commonly affects Caucasian premenarchal girls and postmenopausal
multiple over-the-counter topical therapies without women. The exact etiology is unknown, but is most likely multifactorial.
improvement. She has no significant vaginal discharge. Patients typically present with extreme vulvar pruritus and may also
She has severe dyspareunia at the introitus and has present with vulvar burning, pain and introital dyspareunia. Early skin
stopped having intercourse because of the pain. Her changes include polygonal ivory papules involving the vulva and
past medical history is significant for allergic rhinitis and perianal areas, waxy sheen on the labia minora and clitoris, and
hypertension. On pelvic examination the external hypopigmentation. The vagina is not involved. More advanced skin
genitalia show loss of the labia minora with resorption of changes may include fissures and erosions due to a chronic itch-scratch-
the clitoris (phimosis). The vulvar skin appears thin and itch cycle, mucosal edema and surface vascular changes. Ultimately,
pale and involves the perianal area as in the picture scarring with loss of normal architecture, such as introital stenosis and
below. No ulcerations are present. The vagina is mildly resorption of the clitoris (phimosis) and labia minora, may occur.
atrophic, but appears uninvolved. Which of the following Treatment involves use of high-potency topical steroids. There is less
is the most likely diagnosis in this patient? than a 5% risk of developing squamous cell cancer within a field of lichen
sclerosus.
A. Squamous cell hyperplasia
B. Lichen sclerosus
C. Lichen planus
D. Candidiasis
E. Vulvar cancer
79. A 65-year-old G3P3 woman presents with symptoms of C. Pessary fitting is the least invasive intervention for this patient's
vaginal pressure and heaviness, which seem to worsen symptomatic prolapse. Although a sacrospinous ligament suspension
towards the end of the day. She has a history of three would be an appropriate procedure for this patient, it is invasive and not
vaginal deliveries. Her surgical history is significant for an appropriate first step. Transvaginal tape is used for urinary
hysterectomy for abnormal vaginal bleeding at age 45. incontinence and has no role in the management of this patient. An
On exam, she is found to have a large pelvic prolapse. anterior repair can potentially help with her symptoms, depending on
Which of the following is the most appropriate initial what is contributing most to her prolapse but, again, it is invasive. Topical
treatment of this patient's prolapse? estrogen is unlikely to properly treat her prolapse and related symptoms.
A. Retropubic urethropexy
B. Needle suspension
C. Artificial urethral sphincter
D. Urethral bulking procedure
E. Sling procedure
83. A 74-year-old G0 woman complains of vulvar pain. She C. This patient has a vulvar lesion causing her pain. The next step is
reports that the pain is present every day and she has had it to perform a biopsy to evaluate for vulvar cancer. Estrogen cream
for the past year. It now limits her ability to exercise, and she and clobetasol (a high potency steroid) are treatments for
is no longer able to have sexual relations with her partner. vulvadynia. To diagnosis vulvadynia, all other causes of pain must
On exam, her BMI is 32; blood pressure is 100/60; and heart first be excluded, including infectious etiologies as well as other
rate is 77. Her vulva has an ulcerated lesion near the left vulvar conditions. Laser vaporization and vulvectomy are
labial edge. Which of the following is the next best step in the contraindicated until a definitive diagnosis is made.
management of this patient?
A. Estrogen cream
B. Clobetasol cream
C. Vulva biopsy
D. Laser vaporization of the lesion
E. Vulvectomy
84. A 76-year-old G3P3 woman presents to your office with C. Overflow incontinence is characterized by failure to empty the
worsening urinary incontinence for the past three bladder adequately. This is due to an underactive detrusor muscle
months. She reports increased urinary frequency, (neurologic disorders, diabetes or multiple sclerosis) or obstruction
urgency and nocturia. On examination, she has a mild (postoperative or severe prolapse). A normal post-void residual (PVR) is
cystocele and rectocele. A urine culture is negative. A 50-60 cc. An elevated PVR, usually >300 cc, is found in overflow
post-void residual is 400 cc. Which of the following is incontinence. Stress incontinence occurs when the bladder pressure is
the most likely diagnosis in this patient? greater than the intraurethral pressure. Overactive detrusor contractions
can override the urethral pressure resulting in urine leakage. The mixed
A. Genuine stress incontinence variety includes symptoms related to stress incontinence and urge
B. Detrusor instability incontinence.
C. Overflow incontinence
D. Functional incontinence
E. Mixed incontinence
85. A 90-year-old G7P7 woman presents with severe C. Because of the hydronephrosis due to obstruction, intervention is
vaginal prolapse. The entire apex, anterior and required. Colpocleisis is a procedure where the vagina is surgically
posterior wall are prolapsed beyond the introitus. She obliterated and can be performed quickly without the need for general
cannot urinate without reduction of the prolapse. anesthesia. Anterior and posterior repairs provide no apical support of
Hydronephrosis is noted on ultrasound of the kidneys the vagina. She will be at high risk of recurrent prolapse. The
and thought to be related to the prolapse. She has a sacrospinous fixation (cuff to sacrospinous-coccygeus complex) or
long-standing history of diabetes and cardiac disease. sacrocolpopexy (cuff to sacral promontory using interposed mesh)
She has failed a trial of pessaries. Which of the require regional or general anesthesia and is not the best option for this
following is the next best step in the management of patient with high surgical morbidity.
this patient?
1. A 4-year-old female is being B. Congenital adrenal hyperplasia of the 21-hydroxylase type results in the adrenal being
evaluated for premature hair growth unable to produce adequate cortisol as a result of a partial block in the conversion of 17-
in the pubic area. She has no breast hydroxyprogesterone to desoxycorticosterone, with the accumulation of adrenal androgens.
development and has not had any This leads to precocious adrenarche. Treatment includes steroid replacement. Idiopathic
menstrual bleeding. Laboratory isosexual precocious puberty is GnRH dependent and leads to an appropriate (although
evaluation revealed high DHEA and early) order of pubertal events. Some girls with premature adrenarche develop polycystic
DHEAS levels and low levels of LH ovarian syndrome in adolescence, but not at this age.
and FSH. Which of the following is
the most likely cause of this patient's
premature adrenarche?
A. Pituitary adenoma
B. Congenital adrenal hyperplasia
C. True precocious puberty
D. McCune Albright Syndrome
E. Ovarian neoplasm
3. An 8-year-old female has been B. True precocious puberty is manifested by premature secretion of GnRH hormone in a
diagnosed with precocious puberty pulsatile manner. Once other causes of hormone production are ruled out, treatment would
due to presence of menarche, Tanner include GnRH agonist to suppress pituitary production of follicular-stimulating hormone and
stage III breasts and otherwise luteinizing hormone. Observation is acceptable if the precocious puberty is within a few
normal work-up for brain, adrenal months of the routinely expected puberty. The process should be treated if the bone age or
and ovarian abnormalities. What is puberty is advanced by several years.
the most appropriate next step in the
management of this patient?
A. Depo-Provera
B. GnRH agonist
C. Danazol
D. Estradiol
E. Observation
4. A 9-year-old female goes to the doctor's office for a regular B. The normal and predictable sequence of sexual maturation
check-up. She is healthy, active in school sports and gets good proceeds with breast budding, then adrenarche (hair growth), a
grades. On examination she is 4 feet 8 inches tall and weighs growth spurt and then menarche. In a minority of cases, pubarche
80 pounds. She is concerned about when she might expect to (pubic hair growth) can occur before thelarche (breast/areolar
have her first menstrual period since her friends have been development). Breast development begins around the age of 10
talking about it. On physical examinations, she has Tanner and average age of menarche is 12.7 years for Caucasian girls and
stage 1 breasts and no pubic hair. You explain to her that she 12.1 for Black girls. Menarche also occurs earlier for heavier girls
can expect to experience which of the following first sexual and later for thinner, physically active girls.
developments?
A. Adrenarche
B. Thelarche
C. Growth spurt
D. Menarche
E. Pubarche
5. A 13-year-old female is brought to the physician for D. Lower genital tract malformations occur in 1 in 10,000 females
increasingly severe abdominal pain. The pain is now constant and are most commonly an imperforate hymen where the genital
and mildly uncomfortable, but every month she has a week plate canalization is incomplete. Amenorrhea and abdominal pain
when it is more severe. She has Tanner stage II breasts and are also associated with isolated atresia of the vagina or cervix.
pubic hair development. On genital examination, there is a The menstrual blood will collect in the vagina and uterus causing
bluish mass pushing the labia open. What is the most likely pain. Treatment involves surgical correction. When a transverse
cause of this patient's abdominal pain? vaginal septum is present, a normal vaginal opening with a short
blind vagina and pelvic mass may be located above the level of
A. Turner's syndrome the obstruction found on exam. Asherman's syndrome is
B. Transverse vaginal septum associated with secondary amenorrhea resulting from intrauterine
C. Isolated atresia of the cervix scarring/synechiae.
D. Imperforate hymen
E. Synechiae of the uterine cavity
6. A 14-year-old G0 female reports menarche six months ago, C. Disorders of clotting may present with menstrual symptoms in
with increasingly heavy menstrual flow causing her to miss young women, with Von Willeberand disease being most common.
several days of school. Three months ago, her pediatrician Leiomyomas typically present in women in their 30's and 40's.
started her on oral contraceptives to control her menstrual Endometrial hyperplasia can occur in younger anovulatory
periods, but she continues to bleed heavily. Her previous patients, but the short duration of this patient's symptoms makes
medical history is unremarkable. The patient has a normal this less likely. She does not have any signs of infection or thyroid
body habitus for her age. Appropriate breast and pubic hair disease.
development is present. Her hemoglobin is 9.1 mg/dl,
hematocrit 27.8%, a urine pregnancy test is negative. Which of
the following etiologies for menorrhagia is most likely the
cause of her symptoms?
A. Uterine leiomyoma
B. Thyroid disorder
C. Coagulation disorder
D. Endometrial hyperplasia
E. Chronic endometritis
7. A 15-year-old female mentions to her doctor that she C. Normal age for menarche is between nine and 17. Since this patient has
has never had a menstrual cycle. She is healthy, active secondary sexual characteristics and normal anatomy, she should be
in school activities and eats a normal diet. She denies offered reassurance that she is normal and her menses will probably start
ever being sexually active. On physical examination, soon.
she has Tanner stage II breast and pubic hair growth,
and average weight and height. Vaginal opening is
present and appears normal. What is the most
appropriate next step in her management?
A. Pelvic ultrasound
B. Oral contraceptive pills
C. Reassurance
D. MRI of sella turcica
E. Cortisol challenge test
8. A 15-year-old G0 female presents with severe A. The progestin in oral contraceptives causes endometrial atrophy. Since
menstrual pain for the past 12 months. The pain is prostaglandins are produced in the endometrium, there would be less
severe enough for her to miss school. The pain is not produced. Dysmenorrhea should be improved.
relieved with ibuprofen 600 mg every four hours. She
is not sexually active and the workup reveals no
pathology. Which mechanism of action best explains
why oral contraceptives would be the most
appropriate treatment for this patient?
A. Renal ultrasound
B. Brain MRI
C. FSH and LH determination
D. Cortisol level
E. Testosterone level
12. A 17-year-old G0 female is brought in by her mother because she A. This patient's primary amenorrhea, with normal secondary
has not yet had any menses. She is otherwise in good health, but sexual characteristics, development and cyclical abdominal
recently has been experiencing cyclical lower abdominal pain, points to an anatomical cause of amenorrhea, which is
cramping. She has never had sexual intercourse. She is 5 feet 6 preventing menstrual bleeding. An imperforate hymen
inches tall and weighs 120 pounds. On examination, her breasts are commonly causes this and the treatment is surgical. In
Tanner Stage IV. She has some suprapubic tenderness on Mllerian agenesis, or Mayer-Rokitansky-Kster-Hauser
abdominal exam. Her pelvic exam reveals normal external syndrome, there is congential absence of the vagina and
genitalia, but there was difficulty inserting a speculum due to usually an absence of the uterus and fallopian tubes. Ovarian
patient's discomfort. Beta-hCG < 5 mIU/mL. What is the most likely function is normal and all the secondary sexual characteristics
diagnosis in this patient? of puberty occur at the appropriate time.
A. Estradiol
B. Serum cortisol
C. Urinary cortisol
D. Random blood glucose
E. 17-hydroxyprogesterone
17. A 19-year-old G0 woman presents with severe B. Laparoscopy is recommended to confirm the diagnosis of endometriosis
menstrual pain that causes her to miss school. She and exclude other causes of secondary dysmenorrhea. SSRIs are not used to
takes 600 mg of ibuprofen every four to six hours to treat dysmenorrhea, rather they are a good treatment for PMS. Some authors
control the pain, but this does not relieve the suggest that a course of GnRH agonists are appropriate, with laparoscopy
discomfort. You started oral contraceptives, but her reserved for those women who have pain during or after completion of a
symptoms persisted. She also tried Depo-Provera three-month course, but using estrogen add-back would remove the
for three months without much improvement. She diagnostic sensitivity of the GnRH agonist.
still has menstrual pain and continues to miss some
classes. What is the most appropriate next step in
the management?
A. Copper IUD
B. GnRH agonist
C. Oral contraceptives
D. Continuous medroxyprogesterone
E. Laparoscopy
19. A 20-year-old G0 woman presents with severe B. The US Preventive Services Task Force recommends chlamydia and
menstrual pain. She takes 600 mg of ibuprofen gonorrhea screening for all sexually active patients, age 25 and younger.
every four to six hours to control the pain, but this Since pelvic inflammatory disease is a cause of secondary dysmenorrhea, it
does not relieve the discomfort. She is sexually needs to be evaluated as a potential cause of her symptoms. Although HPV
active with one partner and has four lifetime screening is common, it can be used as an adjunct to cytology in primary
partners. She uses condoms for contraception. Past screening in women 30 years or older, and is not indicated in a 20 year old.
medical history is unremarkable, except for breast Pap smears are not indicated in women under 21 years of age regardless of
cancer in her father's sister. Examination is normal. sexual history. A hysterosalpingogram is used for infertility work-up and will
Which of the following is the most appropriate test not necessarily help determine the cause of her pain. A diagnostic
for this patient? laparoscopy would be premature at this point.
A. Spironolactone
B. Lupron
C. Danazol
D. Depo-Provera
E. Steroids
21. A 22-year-old G0 woman college student returns for A. This woman has premenstrual syndrome (PMS) with symptoms that
follow-up of mood swings and difficulty warrant treatment. Patients with PMS and premenstrual dysphoric disorder
concentrating on her schoolwork the week before (PMDD) experience adverse physical, psychological and behavioral
her menses for the past 12 months. Her past medical symptoms during the luteal phase of the menstrual cycle. PMS is
history is unremarkable and physical examination is characterized by mild to moderate symptoms, while PMDD is associated
normal. Which of the following would be an with severe symptoms that seriously impair usual daily functioning and
appropriate treatment option for this patient? personal relationships. Mild symptoms of PMS often improve by suppressing
the hypothalamic-pituitary-ovarian axis with oral contraceptive pills. Ritalin
A. Oral contraceptive pills and Ginkgo are not effective treatments for PMS. Gabapentin is used for
B. Reassurance and observation neuropathic pain and will not help alleviate her symptoms.
C. Methylphenidate (Ritalin)
D. Gabapentin
E. Ginkgo
22. A 22-year-old G0 woman presents with five months D.Since most women resume normal menstrual cycles after discontinuing
of amenorrhea since discontinuing her oral oral contraceptive pills (OCPs), they are not usually considered the cause of
contraceptive pills. She had been on the pill for the the amenorrhea. A history of irregular cycles prior to pill use may increase
last six years and had normal menses every 28 days the risk of amenorrhea upon discontinuation. This is sometimes referred to
while taking them. She is in good health and not as "post pill amenorrhea." A complete work-up should be performed to
taking any medications. She is 5 feet 4 inches tall and properly find the cause. Although the other historical elements are all
weighs 140 pounds. Her examination, including a important components of a complete gynecological history, they are not
pelvic examination, is normal. Which of the following helpful to find the etiology of amenorrhea in this patient. Significant weight
historical elements would be most useful in loss might cause amenorrhea; however, this patient still has normal body
determining the cause of amenorrhea in this patient? mass index, which makes it unlikely cause of amenorrhea.
A. Estrogen level
B. Progesterone level
C. Gonadotropin releasing hormone level (GnRH)
D. Follicle stimulating hormone (FSH)
E. Dehydroepiandrosterone sulfate (DHEAS)
28. A 23-year-old G0 woman with severe dysmenorrhea C. The lesions described are classic for endometriosis. One would
that is unresponsive to non-steroidal anti-inflammatory therefore expect to see endometrial glands/stroma with hemosiderin-
agents and oral contraceptives is taken to the operating laden macrophages. Hyperplastic overgrowth of endometrial
room for a laparoscopy. Blue-black powder burn lesions glands/stroma is consistent with endometrial polyps. Decidual effect on
are seen in the pelvis. A biopsy is performed and sent to the endometrium are seen during pregnancy. Invasion of endometrial
pathology. Which of the following pathologic findings glands into the myometrium is seen with adenomyosis. Well-
would you expect to see in this patient? circumscribed, non-encapsulated myometrium is consistent with myomas.
A. Ovarian dysfunction
B. Thyroid disease
C. Premature ovarian failure
D. Hypothalamic-pituitary dysfunction
E. Pregnancy
30. A 24-year-old G1P1 woman presents with a complaint of A. The likely cause of this patient's sudden onset of symptom is an
decreasing breast size and hirsutism noted over the last increase in androgens due to a tumor. Hirsutism is often the result of
three months. She also notes her skin feels oily and her a benign condition, however, may be a sign of significant disease if
husband has mentioned her voice seems to be getting sudden in onset and coupled with virilization. Virilization in the
deeper. She has no medical or surgical problems and takes female may be manifested by frontal hair thinning, oily skin or acne,
no medications. Physical examination reveals oily skin, deepening of the voice, clitoral enlargement, menstrual irregularities,
upper lip and chin terminal hair, and normal appearing and increased muscle strength. Possible causes of virilization include
breasts. Pelvic examination reveals her clitoris to be 2 cm in PCOS, hypothyroidism, androgen producing tumors (ovarian,
length and 1 cm wide. Which of the following is the most adrenal, or pituitary), and anabolic steroid use. A rare cause may be
likely cause of her symptom constellation? late onset congenital adrenal hyperplasia.
A. Hyperthyroidism
B. Hyperprolactinemia
C. Atrophic changes of external genitalia
D. Deepening of the voice
E. Hyperparathyroidism
32. A 26-year-old G0 woman presents with hirsutism and A. Acanthosis nigricans is associated with elevated androgen levels
irregular menses. Her mother, who is diabetic, had similar and hyperinsulinemia. Since this woman has a family history of
complaints prior to menopause. On physical exam, this diabetes and also has acanthosis nigricans, the most appropriate test
patient is noted to have terminal hair on her chin and a of those listed would be the fasting insulin. The other tests would
gray-brown velvety discoloration on the back of her neck. also be reasonable, but hyperinsulinemia is most likely in this patient.
This lesion is acanthosis nigricans. Which of the following is
the most appropriate first test to order for this patient?
A. Fasting insulin
B. TSH
C. 17-hydroxyprogesterone level
D. Cortisol level
E. Pelvic ultrasound
33. A 27-year-old G0 woman comes to the clinic because she has been unable A
to conceive for the last year. She is in good health and has not used any
hormonal contraception in the past. She had normal cycles in the past
every 28 days until about six months ago. At that time, she began to have
irregular menses every two to three months, with some spotting in
between. She is not taking any medications. She has no history of
abnormal Pap smears or sexually transmitted infections. Her physical
examination is normal. Laboratory tests show:
A. Begin levothyroxine
B. Begin bromocriptine
C. Order a clomiphene citrate ovulation challenge test
D. Obtain a brain MRI
E. Order a thyroid ultrasound
34. A 27-year-old G0 woman presents to the clinic because of concerns that A. Reassurance and observation is most appropriate
she has not been able to get pregnant for the last three months. She as the patient has only been trying to conceive for
married a year ago and was using condoms for contraception, which she three months. After one month, 20% of couples will
stopped three months ago when she decided to start a family. She is in conceive; after three months, 50%; after six months,
good health and her only medication is a prenatal vitamin. Her periods are 75%; and after 12 months, 90% will conceive. Primary
regular every 28 days with normal flow; her last period was two weeks infertility is defined as the inability to conceive for one
ago. She has no history of sexually transmitted infections and no abnormal year without contraception. The patient is young and
Pap smears. Her husband is also healthy with no medical problems. She is healthy with no obvious reasons for infertility, so at
5 feet 4 inches tall and weighs 130 pounds. Her examination, including a this point reassurance and observation is the proper
pelvic exam, is completely normal. What is the most appropriate next step management. There is no reason to order any studies
in the management of this patient? now, especially since she has normal cycles.
A. Psychogenic amenorrhea
B. Premature ovarian failure
C. Hypothalamic amenorrhea
D. Androgen excess
E. Hyperthyroidism
40. A 31-year-old G3P0 woman presents with D. Asherman's syndrome can be caused by curettage or endometritis. The
amenorrhea for six months. She is otherwise in intrauterine synechiae or adhesions result from trauma to the basal layer of
good health and is not taking any medications. She the endometrium, which causes amenorrhea. Chronic endometritis may be
had a miscarriage seven months ago, which was associated with abnormal uterine bleeding and not amenorrhea.
complicated by an infection and required antibiotics Hypothalamic amenorrhea is unlikely because of the temporal relationship of
and a dilation and curettage procedure. Her her amenorrhea to the procedure. Sheehan's syndrome is typically due to
examination is normal. Her laboratory results show severe postpartum hemorrhage leading to pituitary apoplexy.
a Beta-hCG <5 mIU/mL, and normal TSH and
prolactin levels. What is the most likely underlying
cause of this patient's amenorrhea?
A. Chronic endometritis
B. Recurrent miscarriages
C. Hypothalamic-pituitary amenorrhea
D. Asherman's syndrome
E. Sheehan's syndrome
41. A 32-year-old G0 woman comes to the office due to the inability to conceive B. This patient most likely has PCOS (polycystic
for last two years. She reports having been on oral contraceptives for eight ovarian syndrome) based on her history of irregular
years prior. She had menarche at age 14 and has had irregular cycles about cycles, her body habitus and hirsutism. Having
every three months until she started oral contraceptives, which regulated her normal cycles on the birth control pills (OCPs)
cycles. In the last year, she has had about five cycles in total; her last supports the diagnosis as other causes, such as
menstrual period was six weeks ago. She is otherwise in good health and has hypothyroidism, will not normalize the cycles on
not had any surgeries. She has no history of abnormal Pap smears or OCPs. Testosterone levels will be helpful to
sexually transmitted infections. She is 5 feet 4 inches tall and weighs 165 confirm the diagnosis, especially in the presence of
pounds. On general appearance, she is hirsute on the face and the abdomen. hirsutism. Once a diagnosis is established,
The rest of her exam is otherwise normal. Which of the following is most progesterone levels are helpful during medical
likely to help identify the underlying cause of this woman's infertility? treatment to check if the woman is ovulating. An
increased LH/FSH ratio is observed to be elevated
A. Luteinizing hormone levels in PCOS patients but each test separately will not
B. Testosterone levels aid in the diagnosis.
C. Follicle stimulating hormone levels
D. Thyroid function tests
E. Progesterone levels
42. A 32-year-old G0 woman comes to the office due to the inability to conceive B. This patient has PCOS (polycystic ovarian
for the last two years. She reports having been on oral contraceptives for syndrome) based on her history, signs and
eight years prior. She had menarche at age 14 and had irregular cycles about symptoms. It is most important for her to try to lose
every three months until she started birth control pills, which made her weight. Metformin and ovulation induction agents
cycles regular. In the last year, she has had about five cycles in total; her last are the first-line of treatment for ovulatory
menstrual period was six weeks ago. She is otherwise in good health and has dysfunction in PCOS patients. Since there is known
not had any surgeries. She has no history of abnormal Pap smears or ovulatory dysfunction and there is no reason to
sexually transmitted infections. Her husband of four years is 35-years-old, believe there are problems with semen analysis, IVF
and has a 10-year-old son from a previous marriage. She is 5 feet 4 inches is not justified. There is no role for the laparoscopy
tall and weighs 165 pounds. On general appearance, she is hirsute on the face in this patient. Although oral contraceptives would
and the abdomen. The rest of her exam is otherwise normal. In addition to regulate her cycles, it is not indicated because she
weight loss and starting metformin, what is the most appropriate treatment is trying to get pregnant.
for this patient's infertility problem?
A. Laparoscopy
B. Ovulation induction agents
C. Intrauterine insemination
D. In vitro fertilization
E. Restart oral contraceptives
43. A 32-year-old G0 woman presents with amenorrhea for the last three D. Pregnancy is the most common cause of
months. She has a long history of irregular cycles, 26 to 45 days apart, for amenorrhea. It is important to consider it early in
the last two years. She is otherwise in good health and is not taking any the workup to avoid unnecessary tests, procedures
medications. She is sexually active with her husband and uses condoms for and treatments that may be contraindicated during
contraception. She is 5 feet 4 inches tall and weighs 140 pounds. On exam, pregnancy. Although the patient has a history of
she has a slightly enlarged, non-tender uterus. There are no adnexal masses. irregular cycles and is using condoms for
Which of the following is the most appropriate test to obtain in this patient? contraception, it is important to first rule out
pregnancy before initiating further work-up.
A. Thyroid stimulating hormone (TSH)
B. Progesterone and estrogen
C. Follicle stimulating hormone (FSH)
D. Urine pregnancy test
E. Pelvic ultrasound
44. A 32-year-old G0 woman presents with irregular menses occurring every B. Patients with anovulatory bleeding have
six to eight weeks for the past eight months. The bleeding alternates predominantly proliferative endometrium from
between light and heavy. Her irregular menses were treated successfully unopposed stimulation by estrogen. Progestins inhibit
with medroxyprogesterone acetate (MPA), 10 mg every day, taken for 10 further endometrial growth, converting the
days each month. By which mechanism does the MPA control her periods? proliferative to secretory endometrium. Withdrawal of
the progestin then mimics the effect of the involution
A.Stimulates rapid endometrial growth and regeneration of glandular of the corpus luteum, creating a normal sloughing of
stumps the endometrium. Stimulation of rapid endometrial
B. Converts endometrium from proliferative to secretory growth, conversion of proliferative to secretory
C. Promotes release of Prostaglandin F2 endometrium, and regeneration of the functional
D. Regenerates functional layer of the endometrium layer describe effects of estrogen on the
E. Decreases luteal phase inhibin production endometrium. Inhibin is increased in the luteal phase.
45. A 32-year-old G2P2 woman complains of depression, weight gain and D. Symptoms of hypothyroidism can mimic typical
premenstrual bloating. She has suffered from these symptoms for 18 symptoms of PMS, but symptoms occur more
months and they have not responded to dietary changes and avoidance of constantly throughout the cycle. Diagnosis involves
alcohol and caffeine. Her only medications are multivitamins and herbs to complete work-up to rule out medical illnesses,
increase her energy. She is very concerned about fatigue that often including hypothyroidism. Although fatigue can be
interferes with caring for her two children. A prospective symptom diary associated with anemia, her presentation is not
completed by the patient indicates mood symptoms, fatigue and bloating consistent with this diagnosis.
almost every day of the past two months, and regular menstrual cycles
accompanied by breast tenderness. She denies feelings of wanting to hurt
herself or others. Physical examination is unremarkable. Which of the
following conditions is the most likely explanation for this patient's
symptoms?
A. Panic disorder
B. Anxiety disorder
C. Anemia
D. Hypothyroidism
E. Premenstrual dysphoric disorder
46. A 32-year-old G2P2 woman is concerned about symptoms associated with B. PMDD is a psychiatric diagnosis, describing a
her menstrual cycle. During the second half of her cycle, she feels anxious, severe form of premenstrual syndrome in which the
sad and has difficulty sleeping. She has done research on the Internet and diagnostic criteria include five out of 11 clearly
believes she suffers from premenstrual dysphoric disorder (PMDD). Which defined symptoms, functional impairment and
of the following symptoms of the patient is most consistent with this prospective charting of symptoms present during the
diagnosis? last week of the luteal phase that begin to resolve
with the beginning of the follicular phase. All three
A. Cyclic constellation of symptoms during the follicular phase areas of symptoms need to be represented for the
B. Cyclic occurrence of a minimum of described symptoms and diagnosis of PMDD.
interference in social functioning
C. Chronic, mild depressive symptoms that have been present for many
years
D. Depressed mood or the loss of interest or pleasure in activities
E. Anxiety/nervousness interfering in social functioning
47. A 33-year-old G0 woman presents with amenorrhea for D. The patient's symptom of dyspareunia is likely caused by vaginal
the past 12 months. She also reports a recent onset of dryness, which is associated with estrogen deficiency.
dyspareunia, causing her to feel anxious about having Hypergonadotropic amenorrhea is the result of ovarian failure or
intercourse. She had menarche at age 15. Her cycles follicular resistance to gonadotropin stimulation. The history, physical
were normal until two years ago when she began exam and labs make the other possibilities less likely: psychogenic
skipping menses. She is otherwise in good health. She is disorder (no chronic anxiety or anorexia nervosa), outflow obstruction
5 feet 4 inches tall and weighs 130 pounds. Her physical (previously had periods), Asherman's syndrome (no history of pregnancy
examination is completely normal. TSH and prolactin or intrauterine procedures), or a pituitary tumor (normal labs).
levels are normal. Urine pregnancy test is negative.
What is the most likely cause of this patient's
amenorrhea?
A. Psychogenic
B. Genital tract outflow obstruction
C. Asherman's syndrome
D. Premature ovarian failure
E. Pituitary adenoma
48. A 34-year-old G2P2 woman presents with concerns of A. The most likely diagnosis in this patient is a testosterone-secreting
hormonal changes. She is worried about facial hair ovarian tumor. Sertoli-Leydig cell tumors are commonly diagnosed in
growth, worsening acne, and deepening of her voice. women between the ages of 20-40, and are most often unilateral. Rapid
She also realized that she has missed her period for two onset of hirsutism and virilizing signs are hallmarks of this disease, and
months, and has been sexually active and had tubal include many of the findings in this patient including acne, hirsutism,
ligation. On examination, she is moderately obese and amenorrhea, clitoral hypertrophy, and deepening of the voice. Abnormal
noted to have severe acne, upper lip and chin terminal laboratory findings include suppression of FSH and LH, marked elevation
hair. Her abdomen is obese with moderate hair growth. of testosterone, and presence of an ovarian mass. The constellation of
Pelvic examination is most notable for an enlarged findings is most consistent with a testosterone-secreting tumor, and a
clitoris, and pelvic exam reveals an enlarged right-sided pelvic ultrasound will confirm the presence of an ovarian mass. The other
adnexal mass. Which of the following is the most likely tumors do not cause virilization. Granulosa cell tumors and thecomas are
diagnosis in this patient? estrogen-secreting tumors.
A. Prolactin level
B. Progesterone level
C. Hysterosalpingogram (HSG)
D. Pelvic ultrasound
E. Colposcopy
50. A 35-year-old G0 Asian woman presents with irregular menses and D. The short duration of symptoms and the significantly
hirsutism of three months duration. The patient has no family history elevated DHEAS support the diagnosis of an adrenal
of hirsutism. On exam, the patient was noted to have terminal hair tumor as the etiology of the patient's symptoms. In
growth on her chest and recently had laser treatment to remove addition, the patient is Asian and is less likely to have a
similar hair on her chin. Her total testosterone is 76 ng/dl (normal) and predisposition to idiopathic hirsutism. Asians with
her DHEAS is 1500g/dl (elevated). Which of the following is the most polycystic ovarian syndrome are less likely to present with
likely diagnosis in this patient? overt hirsutism than other ethnic groups.
A. Pituitary adenoma
B. Ovarian tumor
C. Cushing's syndrome
D. Adrenal tumor
E. Idiopathic
51. A 35-year-old G0 woman comes to the office because of six months A. Management of an endometrial polyp includes the
of spotting between her periods and a desire for a pregnancy. She following: observation, medical management with
reports using 30 pads/cycle the last two months and has blood clots progestin, curettage, surgical removal (polypectomy) via
and cramping pain. Prior menses were light and required 15 hysteroscopy, and hysterectomy. Observation is not
pads/cycle. She has been trying to conceive for six months. Her work- recommended if the polyp is > 1.5 cm. In women with
up included a transvaginal ultrasound which revealed a 2 cm infertility polypectomy is the treatment of choice. While
endometrial polyp. What is the next best step in the management of her inability to get pregnant may be more complicated
this patient? than just her polyp, removal of the polyp should occur
prior to infertility treatments.
A. Hysteroscopic polypectomy
B. Observation
C. Combination birth control pills
D. Endometrial ablation
E. In-vitro fertilization
52. A 35-year-old G0 woman presents with irregular menstrual periods E. Endometrial biopsy should be performed to rule out
occurring every six to twelve weeks with occasional inter-menstrual endometrial hyperplasia or carcinoma given the history of
bleeding. Currently, she has been bleeding daily for the last four irregular bleeding, coupled with the increased risk of
weeks. She reports that her periods have always been irregular, but these diagnoses in morbidly obese patients. While an
have become more so with heavier flow and cramping in the last year. ultrasound may be helpful, a pelvic CT is not useful in the
She is sexually active with one partner. On physical exam, she is workup for potential endometrial neoplasia. LH and FSH
morbidly obese with no abnormalities detected on pelvic exam. Which levels would not aid in the diagnostic workup and
of the following is the most appropriate next step in the management testosterone levels would not be useful, unless signs of
of this patient? hirsutism or virilization are present.
A. Endorphins
B. Cortisol
C. Progesterone
D. Estrogen
E. Androgen
57. A 37-year-old G1P1 woman has experienced symptoms of depression D. Selective serotonin reuptake inhibitors increase the
and difficulty concentrating the week prior to her menstrual period for amount of active serotonin in the brain and have been
the last three years, since her tubal ligation. She kept a symptom diary found to be effective in alleviating PMS and PMDD
for three months revealing symptoms clustered around her menstrual symptoms. Patients can take the medication either every
cycle. She was diagnosed with premenstrual syndrome and began a day or for 10 days during the luteal phase. Progesterone
regular exercise routine with dietary modifications, but only noticed mild cream will not help her symptoms. Herbal therapies
relief in her symptoms. Work-up is otherwise unremarkable. Which of the such as evening primrose oil and ginkgo have not been
following will most likely alleviate her symptoms? shown to improve PMDD symptoms. Symptoms due to
hypothyroidism would be present throughout her cycle.
A. Evening primrose oil
B. Ginkgo
C. Progesterone cream
D. Fluoxetine hydrochloride
E. Levothyroxine sodium
58. A 37-year-old G1P1 woman suffers from severe mood swings the week D. Vitamin deficiency of A, E and B6 have been
before her menstrual cycle. The mood swings resolve after she stops associated with an increase in PMS. Replacement of
bleeding. You diagnose her with premenstrual syndrome (PMS) after these vitamins might improve PMS symptoms and avoid
obtaining further history and a normal examination. In addition to further medical therapy.
exercise, which of the following might be suggested to help decrease
this patient's symptoms?
A. Folic acid
B. Ginkgo
C. Fish oil
D. Vitamin B6
E. Potassium
59. A 37-year-old G2P1011 woman comes to the clinic with her C. This patient has hyperprolactinemia due to imipramine. The
husband due to the inability to conceive for the last year. She patient has to be weaned off imipramine (instead of abrupt
reports being in good health and not having problems with her discontinuation to minimize withdrawal symptoms) and placed on
prior pregnancy two years ago, except for some postpartum a more appropriate medication. Once she is off imipramine and
depression for which she was placed on imipramine and which the cause of her elevated prolactin levels is confirmed, her normal
she continues to take. She took birth control pills after her menses should resume. Although MRI of the brain would be a
pregnancy and stopped one year ago, when she began trying reasonable step, it would be premature, and visual field
to conceive. Her periods were regular on the pills, but have examination does not aid in the diagnostic work-up. It would be
been irregular since she stopped taking them. She has no premature to obtain an MRI or begin bromocriptine without this
history of sexually transmitted infections or abnormal Pap intermediate step. An endometrial biopsy is not indicated at this
smears. Her husband is also healthy and he fathered their first point, especially since the patient had normal cycles on OCPs.
child. Her physical examination is completely normal. Although Clomid is used to help with ovulatory dysfunction, the
Laboratory tests show: hyperprolactinemia must be addressed first.
A. Begin bromocriptine
B. Ovulation induction with clomiphene citrate (Clomid)
C. Wean off imipramine
D. Perform a visual field examination
E. Obtain a brain MRI
60. A 37-year-old G3P3 woman complains of severe premenstrual E. The patient's mood swings are influenced by the hormonal shifts
symptoms for the past two years. She finds her mood swings controlled by the hypothalamic-pituitary-ovarian axis. A
and irritability troubling and requests a hysterectomy, as she hysterectomy or endometrial ablation would only resolve the
thinks that this procedure will alleviate her symptoms. Past menstrual bleeding component of this patient's symptoms, and
medical history is only remarkable for high cholesterol and have no effect on the hormonal production of the ovaries.
her physical examination, including pelvic examination, is Removal of her ovaries may improve her symptoms but would
normal. The patient's physician does not recommend a increase her risk for future problems, including osteoporosis and
hysterectomy. Which of the following is the most likely menopausal symptoms. A bilateral oophorectomy would be the
explanation for the physician's recommendation not to last option for this patient as many medical options are available
perform a hysterectomy in this patient? to treat her symptoms.
A. Breast
B. Endometrial
C. Cervical
D. Lung
E. Colorectal
64. A 42-year-old G2P2 woman complains of D. A calendar of symptoms can clarify if there is a cyclic or constant nature of
bloating, mood swings and irritability the week the symptoms. Often women will mistakenly attribute their symptoms to their
prior to her menses. She is convinced that menstrual cycle. Different self-reporting scales have been written to assist
something is wrong with her hormone levels. In patients track their symptoms. Because she is menstruating regularly, there is no
addition to a complete physical examination, role for obtaining serum hormone levels.
which of the following diagnostic tools would
provide information to accurately determine the
diagnosis?
A. Pelvic ultrasound
B. Estradiol level
C. CAGE questionnaire
D. Prospective symptom calendar
E. Mini mental status examination
65. A 42-year-old G2P2 woman undergoes a E. Well-circumscribed, non-encapsulated myometrium confirms the diagnosis of
hysterectomy for definitive treatment of her fibroids. Hyperplastic overgrowth of endometrial glands/stroma is consistent
dysmenorrhea and large uterine fibroids. The with endometrial polyps. Decidual effect on the endometrium are seen during
uterus is sent to pathology. Which of the pregnancy. Invasion of endometrial glands into the myometrium is seen with
following would confirm the diagnosis of adenomyosis.
fibroids?
A. Hysteroscopy
B. Hysterosalpingogram
C. Clomiphene challenge test
D. Sperm penetration assay
E. Basal body temperatures for six months
70. A 48-year-old G2P2 woman comes to your office C. Although there has been a decline in the average age of menarche with
because she has skipped her menstrual period for the the improvement in health and living conditions, the average age of
past three months. She denies any menopausal menopause has remained stable. The Massachusetts Women's Health Study
symptoms. Review of symptoms and physical exam are reports that the average age of menopause is 51.3. This patient is most
unremarkable. What is the most likely diagnosis in this likely perimenopausal and will probably have more menstrual periods in
patient? the future. Although it is important to consider pregnancy and
hypothyroidism, this patient's presentation is most consistent with
A. Hypothyroidism perimenopause. Premature ovarian failure occurs before age 35.
B. Early pregnancy
C. Perimenopause
D. Premature ovarian failure
E. Autoimmune disorder
71. A 49-year-old G1P1 woman comes to your office for E. Recent data have confirmed the overall positive effects of hormone
menopause counseling. She has been experiencing therapy on serum lipid profiles. The most important lipid effects of
severe sleep disturbances and night sweats for the postmenopausal hormone treatment are the reduction in LDL cholesterol
past four months. She would like to begin hormone and the increase in HDL cholesterol. Estrogen increases triglycerides and
therapy, but is concerned because she has elevated increases LDL catabolism, as well as lipoprotein receptor numbers and
cholesterol levels for which she takes medication. You activity, therefore causing decreased LDL levels. Hormones inhibit hepatic
explain to her that hormone therapy has the following lipase activity, which prevents conversion of HDL2 to HDL3, thus increasing
effect on a lipid/cholesterol profile: HDL levels. Hormone therapy is not currently recommended for the
primary prevention of heart disease.
A. Both HDL and LDL levels increase
B. Both HDL and LDL levels decrease
C. HDL and LDL levels are unaffected
D. HDL levels increase and LDL levels are unaffected
E. HDL levels increase and LDL levels decrease
72. A 49-year-old G2P2 woman status post hysterectomy at age 45 for B. Except for estrogen receptor modulator therapy, all of
fibroids presents to your office complaining of severe vasomotor the above treatment options will improve hot flash
symptoms for three months. Hot flashes are affecting her quality of symptoms. Treatment with estrogen is most effective, and
life and she would like to discuss options for treatment. What the current recommendation is for the lowest dose for the
treatment option for hot flashes associated with menopause do you shortest duration of time. Hot flashes will resolve
recommend as the most effective? completely in 90% of patients receiving this therapy.
Raloxifene, a selective estrogen receptor modulator, may
A. Lifestyle modifications such as dressing in layers actually cause hot flashes to worsen in a patient who has
B. Estrogen not stopped having these symptoms completely. SSRI
C. Selective estrogen receptor modulator (SERMs) antidepressants, some anti-seizure medications and
D. Selective serotonin reuptake inhibitors (SSRIs) alternative treatments, such as soy products and herbs,
E. Treatment with phytoestrogen (soy) have not been shown to be as effective as estrogen.
73. A 51-year-old G1P1 woman presents for annual examination. She A. Expectant management is reasonable in this patient, as
notes vaginal dryness, some hot flashes, and fatigue. She reports that she notes minimal menopausal symptoms. Her vaginal
her last menstrual period was 14 months ago. She and her husband dryness is not interfering with her ability to enjoy
use lubrication for intercourse, and she denies any significant pain. intercourse, and she has only occasional hot flashes. An
Her past medical history is significant for hypertension, which she FSH level is not indicated as by definition she is menopausal
controls with diet and regular exercise. She is concerned that she given amenorrhea for greater than 12 months. Estrogen and
should begin hormone replacement, because her mother started HRT LH levels are not indicated in the diagnosis of menopause.
around the same age. Which of the following is the most appropriate While HRT is appropriate for patients with significant
next step in her management? menopausal symptoms, and should be used at the lowest
effective dose for the shortest amount of time, this patient
A. Expectant management at this time is not experiencing significant symptoms and
B. FSH level therefore HRT should not be initiated at this time.
C. LH level
D. Estrogen level
E. Initiate combination HRT
74. A 53-year-old G2P2 woman comes to your office complaining of six A. The principal symptom of endometrial cancer is
months of worsening hot flashes, vaginal dryness, night sweats, and abnormal vaginal bleeding. Although the patient's
sleep disturbances. Her last normal menstrual period was six months worsening symptoms make treatment an important
ago and she has been experiencing intermittent small amounts of consideration, the specific organic cause(s) of abnormal
vaginal bleeding. Her medical history is significant for hypertension, bleeding must be ruled out prior to initiating therapy. A
which is well-controlled by a calcium-channel blocker, type 2 tissue diagnosis consistent with normal endometrium or a
diabetes, for which she takes metformin, and hyperthyroidism, for pelvic ultrasound with an endometrial stripe of <4 mm
which she takes propylthiouracil. The patient is 5 feet 7 inches tall ought to be documented. In addition, risks and benefits of
and weighs 140 pounds. Blood pressure is 120/70. Physical hormone replacement therapy must be discussed with this
examination is unremarkable. Which of the following medical patient at length prior to beginning treatment.
conditions in this patient is a contraindication to treatment of
menopausal symptoms with hormone therapy?
A. Vaginal bleeding
B. Hypertension
C. Diabetes
D. Osteoporosis
E. Hyperthyroidism
75. A 54-year-old G2P2 woman presents to your office for A. The American College of Obstetricians and Gynecologists (ACOG)
a health maintenance examination. Her last menstrual recommendations on hormone replacement therapy considers hormone
period was eight months ago. She complains of severe replacement therapy (HRT) the most effective treatment for severe
vasomotor symptoms, vaginal dryness, and menopausal symptoms that include hot flashes, night sweats and vaginal
dyspareunia, and desires treatment for her symptoms. dryness. The physician should counsel the woman about the risks and
She has otherwise been in good health and has no benefits before initiating treatment. ACOG recommends "the smallest
significant past medical or surgical history. Her family effective dose for the shortest possible time and annual reviews of the
history is significant for a mother who has severe decision to take hormones." HRT should not be used to prevent
osteoporosis at the age of 75, a grandmother who died cardiovascular disease due to the slight increase in risk of breast cancer,
of breast cancer at the age of 79, and a father who died myocardial infarction, cerebrovascular accident, and thromoboembolic
at age 77 from a myocardial infarction. She denies events. A woman with an intact uterus should not use estrogen-only
smoking, alcohol or drug use. On physical exam her BP therapy because of the increased risk of endometrial cancer. In addition
is 130/78, pulse is 84, and BMI is 26. The remainder of to the same risks as FDA approved treatments, bioidentical hormones
her exam is within normal limits except for severe such as testosterone and progesterone cream may have additional
vaginal atrophy noted on the pelvic examination. The associated risks. While her family history is significant for one second
best recommendation for this patient would include degree relative with breast cancer, this is not an absolute
which of the following? contraindication for short-term HRT.
A. None
B. 400 mg
C. 800 mg
D. 1200 mg
E. 1600 mg
79. A 58-year-old G3P3 woman who has been menopausal since A. The World Health Organization (WHO) defines osteopenia (low
age 50 comes to you for a health maintenance examination. bone mass) as -1 to -2.5. The American College of Obstetricians and
She is in good health, eats a balanced diet, exercises Gynecologists (ACOG) Committee Opinion recommends that
regularly, and has an unremarkable physical exam. Her bone physicians interpret T scores between 1.0 and 2.5 in combination
mineral density as determined by central dual energy X-ray with the patient's risk factors for fracture. The authors state:
absorptiometry is -1.7. She wants to discuss treatment for her "Clinicians must be careful because the diagnosis of osteopenia
osteopenia. What is the next step in the management of this often is interpreted as indicating a pathologic skeletal condition or
patient? significant bone loss, neither of which is necessarily true. Until better
models of absolute fracture risk exist, postmenopausal women in
A. Evaluate her risk factors for fracture their 50s with T scores in the osteopenia range and without risk
B. Determine her frequency of exercise factors may well benefit from counseling on calcium and vitamin D
C. Assess her exogenous dietary intake of estrogen intake and risk factor reduction to delay initiation of pharmacologic
D. Assess her exogenous dietary intake of progesterone intervention." Some of the risk factors for fracture include prior
E. Repeat DEXA scan in one year fracture, family history of osteoporosis, race, dementia, history of
falls, poor nutrition, smoking, low body mass index, estrogen
deficiency, alcoholism, and insufficient physical activity.
80. A mother brings her 16-year-old daughter to D. The genetic defect of Turner syndrome is the absence of one of the X
the doctor because she has not begun menses. chromosomes. These females have failure to establish secondary sexual
She performs poorly in school because of characteristics, short stature and characteristic physical features: pterygium colli,
dyslexia. On physical examination, she is 4 feet shield chest and cubitus valgus. Partial deletions of the long arm of the X
11 inches tall, 100 pounds and has Tanner stage chromosome also cause premature ovarian failure. The average age of puberty in
I breast and pubic hair growth. Her chest is females with Down syndrome is not significantly different than normal females.
broad, breast nipples are widely spaced and Clinically, patients with Noonan syndrome typically have normal puberty and
her neck is thickened. No genital tract fertility. They may have short stature, webbed neck, heart defects, and abnormal
abnormalities are noted on exam. Which of the faces. Individuals with Noonan syndrome have a normal karyotype. Rokitansky-
following is the most likely cause of her Kuster-Hauser Syndrome causes vaginal and uterine agenesis and is not suspected
delayed sexual maturation? in this case due to the normal pelvic exam findings.
1. A 17-year-old G0 female presents with vaginal spotting C. In the face of discrepancy between dates and uterine size, a pelvic
for the last three days. Her last menstrual period was six ultrasound is indicated to confirm dates, exclude multiple gestation,
weeks ago. Vitals signs are normal. Abdominal and pelvic uterine abnormalities, and molar pregnancy. There is no single Beta-hCG
examination reveals a 10-week sized uterus. Beta-HCG is value that is diagnostic for a molar pregnancy. A quantitative Beta-hCG,
80,000 mIU. What is the best next step in the though, is crucial at determining whether or not a pelvic (transvaginal)
management of this patient? ultrasound will confirm a very early gestation. With a Beta-hCG above
the discriminatory zone (>1500 mIU), an IUP should be easily identified
A. Repeat Beta-HCG in 24 hours on transvaginal ultrasound. If an IUP is not seen, the ultrasound findings
B. Repeat Beta-HCG in 48 hours (in conjunction with the Beta-hCG level) should identify a mole (multiple
C. Pelvic ultrasound internal echoes) or an ectopic (absence of intra-uterine gestation).
D. Dilation and curettage Additional Beta-HCG levels are not indicated at this time. Suction
E. Routine prenatal care curettage will provide a pathologic specimen that can distinguish
between a normal and molar pregnancy, but it is used only as a
therapeutic intervention. Routine prenatal care would be appropriate
only after establishing a normal pregnancy.
2. A 17-year-old G0 sexually active female presents to the D. Although all of the tests listed above may be considered, it is
emergency room with acute right lower quadrant pain imperative to obtain a Beta-HCG to rule out an ectopic pregnancy.
and nausea for 12 hours. Her periods have always been
irregular, with her last one six weeks ago. She is
otherwise completely healthy. She appears in mild
distress. Physical examination: temperature 100.2F
(37.9C); blood pressure 110/60; heart rate 108 beats/min.
She has moderate abdominal tenderness with right
greater than left pelvic tenderness. Pelvic examination
reveals normal external genitalia and pink-tinged
discharge is noted on speculum examination.
Bimanual/rectovaginal examination confirms mild
cervical motion tenderness and fullness in the right
adnexa with moderate tenderness and some voluntary
guarding. What is the single most important test to
obtain?
A. Pelvic ultrasound
B. CT scan of the abdomen and pelvis
C. GC and chlamydia DNA probe
D. Beta-hCG
E. CBC with differential
3. An 18-year-old G0 woman presents to C. A woman's risk for development of ovarian cancer during her lifetime is
discuss contraception. Her best friend's approximately 1%. Factors associated with development of ovarian cancer include low
mother was just diagnosed with ovarian parity and delayed childbearing. Long-term suppression of ovulation appears to be
cancer. The patient is healthy and does not protective against the development of ovarian cancer. Oral contraceptives that cause
have any significant medical history. She anovulation appear to provide protection against the development of ovarian cancer.
does not have a family history of ovarian, Five years cumulative use decreases the lifetime risk by one-half. Risk reducing
breast or any other malignancies. She uses salpingo-oophorectomy is not a practical choice for this patient with no family history,
condoms for birth control. She would like to even once she completes childbearing. This option might be considered for a woman
know what she can do to minimize her risk with a strong family history and the BRCA mutation.
for developing ovarian cancer. Which of the
following recommendations is the most
appropriate for this patient?
ACOG recommends that women who have been vaccinated against HPV should
follow the same screening guidelines as unvaccinated women.
6. A 21-year-old G0 woman presents for her first C. The ASCCP (American Society of Colposcopy and Cervical Pathology)
pelvic examination. She is completely recommends that management options for ASCUS include performing HPV DNA
asymptomatic, healthy, and reports having only testing or repeat cytology at 12 months following the abnormal Pap test result. If
one sexual partner. She uses condoms for the HPV testing is negative (as was reported in this case), then routine screening
contraception. On examination, the patient has can be resumed at three years. If HPV is positive, or if repeat cytology at 12
a normal appearing cervix except for minimal, months reveals ASCUS or higher, then colposcopy should be performed. For
non-malodorous vaginal discharge. Chlamydia women ages 21-24, if HPV is positive, then repeat cytology at 12 months is
and gonorrhea screening is performed, as well recommended with colposcopy performed only if the repeat cytology reveals
as a Pap test. The Pap test is read as ASCUS ASC-H (atypical squamous cell - cannot rule out high grade squamous
(atypical squamous cells of undetermined intraepithelial lesion), AGC (atypical glandular cells) or HSIL (high-grade
significance), HPV negative, and her cultures squamous intraepithelial lesion). The presence of an underlying infection does not
are negative. Which of the following is the most affect the triage of an abnormal Pap smear but may explain the presence of
appropriate management strategy for this ASCUS. See ASCCP guidelines:
patient? http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf
A. Endometrioma
B. Functional ovarian cyst
C. Mucinous cystadenoma
D. Serous cystadenoma
E. Dermoid
11. A 26-year-old G2P1 woman presents with early D. This patient most likely has metastatic GTD given the constellation of
pregnancy and vaginal spotting. Her last normal findings, and elevated Beta-hCG with no evidence of an intrauterine
menstrual period was three months ago, and she pregnancy. Although evacuation is likely necessary, the finding of a vaginal
had a positive home pregnancy test two weeks ago. nodule raises the suspicion of metastasis and further warrants a full staging
She has been experiencing severe morning evaluation with a CT scan of the chest, abdomen and pelvis. A brain MRI is
sickness. She denies any pelvic cramping or also likely. A simple CXR would not be sufficient since she already has
abdominal pain. She is otherwise healthy. On evidence of metastasis to the vagina. Since metastatic GTD is known to be
physical examination, she has a palpable uterus quite vascular, suspicious lesions should not be biopsied. A PET scan has not
just above the symphysis. Pelvic examination is been shown to be a preferred method of evaluation at this time.
notable for a 2 cm fleshy friable nodular lesion
along the left lateral vaginal sidewall, the cervix is
multiparous, with a small amount of blood in the
vault. Bimanual examination confirms a 10-week
sized uterus. A pelvic ultrasound confirms a
snowstorm pattern, and Beta-hCG is 52,000 mIU.
What is the next step in the management of this
patient?
A. Chest X-Ray
B. Biopsy the vaginal lesion
C. PET scan
D. CT scan of the chest/abdomen/pelvis
E. Evacuation of the uterus
12. A 28-year-old G0 woman has a high-grade squamous E. Punctations and mosaicism represent new blood vessels on end and on
intraepithelial lesion (HSIL) on a Pap test. She has no their sides, respectively. Atypical vessels usually represent a greater degree
complaints. She smokes one pack of cigarettes per of angiogenesis and, thus, usually a more concerning lesion. An ectropion
day. Her pelvic exam is normal. Colposcopy is is an area of columnar epithelium that has not yet undergone squamous
performed. The cervix is noted to have an ectropion metaplasia. It appears as a reddish ring of tissue surrounding the external
and there is abundant acetowhite epithelium. os. Acetowhite epithelium can represent dysplasia but, in most cases, is less
Mosaicism, punctations and several disorderly concerning than the above vascular changes.
atypical vessels are noted. Three biopsies are
obtained and sent to pathology. Which of the findings
on this patient's colposcopy is most concerning?
A. Ectropion
B. Acetowhite epithelium
C. Mosaicism
D. Punctations
E. Disorderly atypical vessels
13. A 28-year-old G0 woman with a low-grade squamous D. Cervical conization is indicated in this patient who has a positive ECC.
intraepithelial lesion (LSIL) on a Pap test presents for Hysterectomy is the treatment for invasive cancer. Waiting six months can
evaluation. A colposcopy is performed and is potentially be harmful, as the lesion can progress or a higher-grade lesion
satisfactory. A lesion is seen at 3:00 that turns white might already be present. Cryotherapy will not provide a pathologic
with acetic acid, has punctations and mosaicism, and is specimen to rule out invasive cancer, but can be used to treat cervical
friable. This lesion is biopsied with a pathology report dysplasia once cancer has been completely ruled out and the entire lesion
of CIN 1. The patient's endocervical curettage (ECC) is can be visualized.
positive for a high-grade lesion. Which of the
following is the most appropriate next step in the
management of this patient?
A. Quantitative Beta-hCG
B. Serum CA-125
C. Transvaginal ultrasound
D. Fine needle aspiration of the liver lesions
E. Biopsy of a chest nodule
15. A 28-year-old G2P0020 experienced her A. Leiomyomas are an infrequent cause of miscarriages and subfertility either by
second miscarriage within 14 months. A recent mechanical obstruction or distortion (and interference with implantation). When a
ultrasound was notable for two uterine fibroids. mechanical obstruction of fallopian tubes, cervical canal or endometrial cavity is
The patient is worried that the fibroids may have present and no other cause of infertility or recurrent miscarriage can be
caused her early pregnancy losses. She is identified, myomectomy is usually followed by a prompt achievement of
otherwise healthy and has no previous pregnancy. Submucosal or intracavitary myomas are most likely to cause lower
surgeries. She presents to you for further pregnancy and implantation rates. Presumed mechanisms include: 1) focal
consultation. Which type of fibroid is the most endometrial vascular disturbance; 2) endometrial inflammation, and; 3) secretion
likely explanation of her miscarriages? of vasoactive substances. Submucosal fibroids are best treated by hysteroscopic
resection.
A. Submucosal
B. Intramural
C. Subserosal
D. Pedunculated
E. Cervical
16. A 30-year-old G1P1 woman presents to the D. The most common tumor found in women of all ages is the dermoid. The
emergency department with left-sided median age of occurrence is 30 years, and 80% occur during the reproductive
abdominal pain. Physical examination is notable years. Dermoids may contain differentiated tissue from all three embryonic germ
for a 5 x 6 cm mobile left adnexal mass. An layers. Dermoid tumors can contain teeth, hair, sweat and sebaceous glands,
ultrasound is performed, which shows a left cartilage, bone, and fat.
ovarian mass with cystic and solid components.
Which of the following is the most likely
diagnosis in this patient?
A. Serous cystadenoma
B. Mucinous cystadenoma
C. Endometrioid tumor
D. Dermoid tumor
E. Brenner tumor
17. A 30-year-old G3P1 woman undergoes an B. The recurrent risk for molar pregnancies ranges from 1 to 2%, which is a 20-fold
uncomplicated dilation and curettage for a first- increase from background risk. The risk of recurrence after two molar pregnancies
trimester miscarriage. Pathology reveals a is 10%.
complete mole. The patient's medical history is
significant for chronic hypertension. She has a
history of a previous uncomplicated term
pregnancy and a termination of a pregnancy at
16 weeks gestation with trisomy 18. What is the
risk of her developing a recurrent molar
pregnancy?
A. Hidradenitis suppurativa
B. Molluscum contagiosum
C. Vulvar intraepithelial neoplasia
D. Melanoma
E. Paget's disease
26. A 39-year-old G1P1 woman comes to see you because of B. The goals of medical therapy are to temporarily reduce symptoms
increased bleeding due to her known uterine fibroids, and to reduce myoma size. The therapy of choice is treatment with a
especially during her menses. She reports that her bleeding GnRH agonist. The mean uterine size decreases 30-64% after three
is so heavy that she has to miss two days of work every to six months of GnRH agonist treatment. Unfortunately, GnRH
month. She has been using oral contraceptives and NSAIDs. agonist therapy is recommended for only a short period of time (3-6
Her most recent hematocrit was 27%. She is undecided about months) typically before a surgical procedure, or to bridge a woman
having more children. You discuss with her short and long- who is close to menopause. In this case, it is the best short-term
term options to decrease her bleeding. What is the next best option. Even though she is anemic, she is asymptomatic and able to
step in the management of this patient? work so a blood transfusion will not be indicated. Although uterine
artery embolization and endometrial ablation effectively reduce
A. Blood transfusion bleeding, pain and fibroid size, they are contraindicated in a patient
B. Gonadotropin-releasing hormone agonists who desires future fertility. The failure rate is about 10-15%. A
C. Endometrial ablation hysterectomy would obviously take care of her bleeding but would
D. Uterine artery embolization not be performed if she desires future fertility.
E. Hysterectomy
27. A 39-year-old G4P3 woman with an ultrasound report D. Suction curettage is the standard management for molar
suggestive of a molar pregnancy is referred for evaluation. pregnancies. Hysterectomy can be considered in women who have
She is asymptomatic. Her uterus is 16-weeks size and her completed childbearing, however, the morbidity of a hysterectomy is
Beta-hCG is >200,000 mIU/mL. What is the recommended still considered greater than suction curettage. Induction with
treatment for this patient? oxytocin would result in severe bleeding once cervical dilation and
contractions developed, and expectant management would risk
A. Expectant management increased growth and progression of the mole (as well as the similar
B. Induction with oxytocin unnecessary risk of bleeding.) Methotrexate may become necessary
C. Methotrexate if she develops post-molar GTD, but not as a sole means of primary
D. Suction curettage treatment.
E. Hysterectomy
28. A 42-year-old G2P2 woman presents to the office C. This lesion may be melanoma and a biopsy must be done to exclude
because she recently noticed a pigmented lesion on her this diagnosis. The concerning features are the size and irregularity of
vulva. She does not know how long it has been there and the lesion. Melanoma represents 5% of vulvar cancer, which is not
it doesn't bother her except that she is worried that she insignificant given the lack of sun exposure and the relatively small
may have warts. Her screening Paps have been negative. surface area. There is no variability in the coloration, ulceration or
Her prior exams have been reported as normal. She is a thickening of the lesion to suggest malignancy at this time. Squamous
nonsmoker. Examination of her vulva reveals a pigmented, cell carcinoma is typically not pigmented. Paget's disease is usually
flat lesion, approximately 1.5 cm in largest diameter at the erythematous with a lacy white mottling of the surface. Condyloma
base of the right labia. It is non-tender. No induration is lesions have a characteristic verrucous appearance. With lichen
present. Her groin examination reveals no adenopathy. sclerosus, the skin appears thin, inelastic and white, with a "crinkled
Her vagina and cervix are well estrogenized and without tissue paper" appearance. Although not listed as an option, the most
obvious lesions. Which of the following is the most likely likely diagnosis is high-grade vulvar intraepithelial neoplasia, which can
diagnosis? have the same clinical appearance.
A. Vulvar condyloma
B. Squamous cell carcinoma
C. Melanoma in situ
D. Paget's disease
E. Lichen sclerosus
29. A 44-year-old G0 woman returns to the office for a post B. In all patients with advanced ovarian cancer, post-operative
operative check following tumor debulking for stage IIIB chemotherapy with a combination of a taxane and platinum adjunct is
endometrioid adenocarcinoma of the ovary. Her medical considered standard of care in the United States. Women who undergo
history is significant for diabetes, hypertension, obesity, surgical cytoreduction, followed by chemotherapy, have a better
hypercholesterolemia and major depression. Which of the overall survival rate than those who undergo surgery alone. The overall
following is the most appropriate next step in the response rate in women with advanced ovarian cancer following
management of this patient? surgery and 4-6 cycles of combination chemotherapy with a taxane
and platinum adjunct is 60-80%. The overall five-year survival for
A. Hospice women with stage III and IV disease is approximately 30%. Second
B. Chemotherapy look laparotomy is no longer considered standard of care.
C. Surveillance
D. Pelvic radiation
E. Second look laparotomy
30. A 44-year-old G1P1 woman was placed on three months B. Maximal response is usually achieved by three months of GnRH
of a GnRH agonist in order to diminish the size of a 5 cm agonist treatment. The reduction in size correlates with the estradiol
submucosal myoma and allow it to be accessible to a level and with body weight. Hot flashes are experienced by >75% of
hysteroscopic removal. About two weeks prior to surgery, patients, usually in three to four weeks after start of treatment,
she was no longer having severe menorrhagia although although they should not persist for longer than one to two months
the drug side effects were becoming incapacitating from end of treatment. After cessation of treatment, menses return in
especially the hot flashes. She decides to cancel the four to ten weeks, and myoma and uterine size return to pretreatment
surgery and she stops the GnRH agonist. Which of the levels in three to four months. The regrowth is consistent with the fact
following is most likely to happen to the myoma? that reduction in size is not due to a cytotoxic effect. However, it is not
true that secondary to the GnRH agonist withdrawal they will grow at a
A. Continues to regress more rapid rate.
B. Resumes former growth potential
C. Grows but to half of its original size
D. Grows at a more rapid rate
E. Becomes hemorrhagic
31. A 44-year-old G2P2 woman presents with six months of intermittent vulvar B. These lesions most likely represent an HPV-
itching. She denies any bleeding, but does have a whitish discharge. She has related condition such as condyloma or vulvar
not felt any obvious lumps or sores. She was diagnosed with lupus over 10 dysplasia. Women who are on immunosuppressive
years ago and is on prednisone, mycophenolate mofetil (CellCept), and therapy are at higher risk of such conditions and
hydroxychloroquine (Plaquenil). Her periods are irregular and her Pap require close surveillance. Although, her history of
smears have been normal, and her last one was 5 years ago. She reports prior treatment for warts suggests these could be
treatment in the past for warts when she was first diagnosed with lupus, but condyloma again, their flat, subtle appearance
denies any other sexually transmitted infections. Examination of the vulva is raises a concern that they may be dysplastic lesions,
notable for diffuse, erythematous labia, with a thin white filmy discharge. and biopsy is indicated. Treatment for presumed
There appears to be subtle but multi-focal, flat, whitish lesions measuring yeast infection is reasonable, given her
0.5 - 1 cm on the labia bilaterally. Her remaining pelvic exam is susceptibility, but would not be the sole treatment in
unremarkable. A saline and potassium hydroxide wet prep is performed and this setting of new clinically evident lesions
is negative. What is the most appropriate next step in the management of especially in light of a negative wet prep. Wide
this patient? excision is not indicated at this time without a
diagnosis.
A. Treatment with oral fluconazole and a topical imidazole
B. Biopsy of the vulvar lesions
C. Treatment of the lesions with topical trichloroacetic acid
D. Wide local excision of the vulva
E. Adjustment of her immunosuppressive therapies
32. A 45-year-old G3P3 woman presents to the office because of a large dark C. VIN III should be treated with local superficial
spot on her vulva. She states that the lesion has been present for at least excision. Even with complete removal of all gross
two years and is occasionally itchy. She has smoked since age 20. She has a disease, recurrence is still possible and the patient
history of genital herpes, but only has one or two recurrences a year. On will need close surveillance. It is inappropriate to do
examination, a 2.5 cm lesion is noted. No induration or groin radical surgery in this setting as cancer has not been
lymphadenopathy is noted. The vagina and cervix appear normal. There are diagnosed. Treatment with TCA and Aldara are
no additional lesions noted on colposcopic examination of the vulva. A reserved for condyloma, although some studies
biopsy of the lesion returns as vulvar intraepithelial neoplasia grade 3 (VIN have shown utility in the use of Aldara in treating
3). What is the most appropriate next step in the management of this low grade VIN. Cryotherapy is primarily used to
patient? treat cervical dysplasia.
A. CIN 1
B. CIN 2
C. CIN 3
D. Carcinoma in situ
E. Microinvasive cervical cancer
38. A 49-year-old G0 woman reports that her periods have D. Growth of uterine fibroids is stimulated by estrogen. Gonadotropin-
become heavier over the last year. The patient's releasing hormone agonists inhibit endogenous estrogen production by
physical exam is notable for a slightly enlarged, suppressing the hypothalamic-pituitary-ovarian axis. They can result in a
irregularly shaped uterus, measuring approximately 40-60% reduction in uterine size. This treatment is commonly used for
eight weeks in size. A pelvic ultrasound confirms the three to six months before a planned hysterectomy in an attempt to
presence of two 2 x 2 cm intramural uterine fibroids. decrease the size of the uterus, which may lead to a technically easier
Her endometrial biopsy reveals proliferative surgery and decreased intraoperative blood loss. In patients who are not
endometrium. The patient's friend recently had a yet menopausal, once the gonadotropin-releasing hormone agonist
hysterectomy due to uterine fibroids and menorrhagia, therapy is discontinued, the fibroids may grow again with re-exposure to
but she would like to avoid having surgery. She is endogenous estrogen. Thus, this therapy may be most useful for women
interested in the medical options for treating who are close to menopause, as this patient is at age 49. Aspirin and
symptomatic uterine fibroids, but has tried NSAIDs methotrexate are not effective treatments for fibroids. Methotrexate is
which did not seem to help much. What is the next best used in ectopic pregnancies. Aspirin and indomethacin will likely not help,
step in the management of this patient? as she did not respond to NSAIDs.
A. Aspirin
B. Methotrexate
C. Estrogen
D. Gonadotropin-releasing hormone agonists
E. Indomethacin
39. A 49-year-old G5P5 woman presents for her first health C. The majority of risk factors for cervical cancer are related to HPV
maintenance examination since she had her last child 10 exposure and include early-onset sexual activity, multiple sexual
years ago. She has no health complaints. She has had partners, a sexual partner with multiple partners, history of HPV or other
two sexual partners. She smokes three to five cigarettes sexually transmitted diseases, immunosuppression, smoking, low
per day, and has been smoking for the past 15 years. socioeconomic status and a lack of regular Pap tests. In this patient with
Last month, her mother underwent a radical multiple risk factors, the presence of an HPV-related condition (vaginal
hysterectomy for Stage 1B cervical carcinoma. Her condyloma) already indicates infection with HPV. Although the HPV type
pelvic examination is normal, except for mucopurulent associated with condyloma is typically a low risk strain (e.g. types 6 and
discharge and vaginal condyloma. Which of the 11), she is also at risk of having been exposed to high-risk types that are
following is the patient's greatest risk for developing typically associated with high-grade dysplasia and cervical cancer (e.g.
cervical cancer? types 16 and 18).
Gynecologic Cancers:
Uterine 52%
Ovary 26%
Cervix 14%
Vulva 5%
Vagina 3%
53. A 72-year-old G3P2 postmenopausal woman is referred by her C. The most useful radiologic tool for evaluating the entire
internist after work-up for abdominal bloating revealed a large peritoneal cavity and the retroperitoneum is computerized
pelvic mass on transvaginal ultrasound and an elevated CA-125. tomography. Specifically in this patient, it would be important to
The patient had a normal colonoscopy and mammography two look for significant involvement of the omentum. A chest x-ray
months ago. The patient's greatest complaint is early satiety and provides adequate evaluation of the chest, unless it is abnormal.
upper abdominal discomfort. Her physical exam is notable for If there is a suspicion for chest involvement on the chest film,
moderate abdominal distension and a significant fluid wave. then a chest CT is necessary. With a normal colonoscopy and no
Pelvic examination confirms a smooth, but fixed pelvic mass symptoms suggestive of colonic obstruction, a barium enema
filling the cul de sac and extending to the umbilicus. Which of would not be useful. PET scan, to date, has not been shown to
the following tests would be most helpful in assessing the extent play a role in the initial evaluation of women with a suspected
of disease? ovarian malignancy. However, PET scan may play a role in
evaluating women with a known diagnosis of ovarian cancer
A. Barium enema who have a suspected recurrence. An IVP would be useful if
B. PET scan there was suspected ureteral obstruction, but otherwise is quite
C. CT scan of abdomen and pelvis limited in assessing the entire abdominal/pelvic cavity.
D. Chest X-ray
E. Intravenous pyelogram
54. A 72-year-old G3P3 presents to the emergency room A. Endometrial cancer is a disease that typically presents with
complaining of abnormal vaginal discharge for the past two symptoms and clinical findings that lead to an early diagnosis.
months. She has had two episodes of vaginal bleeding over the The most common symptom is abnormal postmenopausal
last year. She used combination hormone replacement therapy bleeding. However, other symptoms or clinical findings that may
for 10 years when she went through menopause at age 58, but be seen include abnormal vaginal discharge and lower
stopped once the Women's Health Initiative report came out. Her abdominal discomfort. Endometrial cancer can increase the size
last gynecologic exam and Pap smear were two years ago and of the uterus as it grows, but is usually not the most common
were normal. She has tried several over-the-counter antifungal finding given the early diagnosis of this cancer. Unopposed
creams for what she presumed was a yeast infection; however, estrogen replacement therapy does increase the risk, but not
she reports no change in the nature of the discharge. She does when taken in combination. Early menarche and late menopause
note that she has some mild lower abdominal discomfort. The are additional risk factors that may be related to endometrial
only significant finding on exam is a mucopurulent discharge cancer development.
from a multiparous cervical os. She has a 10-week sized globular
uterus. Which of the following findings is most concerning for
presence of endometrial cancer?
A. Vaginal bleeding
B. Late menopause
C. Abnormal vaginal discharge
D. Enlarged uterus
E. Hormone replacement therapy
55. A 72-year-old woman presents to the office reporting a history B. Given the findings of obvious, moderately differentiated
of vulvar itching that has been worsening over the last six carcinoma, definitive treatment can be recommended with
months. She has a long history of lichen sclerosus, for which she radical vulvectomy and groin node dissection. Only
has not been receiving treatment. On exam, you find an microinvasive squamous cell carcinoma of the vulva can be
irregular-shaped lesion which measures 3.5 cm in greatest treated by wide local excision, but it is a diagnosis that is only
dimension, suspicious for malignancy. You perform a punch made after pathology evaluation of a small (<2 cm), well-
biopsy at the edge of the lesion and send it for pathologic differentiated lesion, with invasion <1.0 mm. Excisional biopsy is
evaluation. The pathologist reports an invasive moderately not indicated given the larger lesion and confirmed finding of
differentiated squamous cell carcinoma. Which of the following cancer. It would be inappropriate to laser a malignant lesion.
is the most appropriate treatment for this patient? Squamous cell carcinoma is the most common vulvar
malignancy and may arise in the setting of chronic irritation from
A. Treatment with a topical steroid lichen sclerosus. Steroids would treat the lichen sclerosus, but
B. Radical vulvectomy and groin node dissection would only result in needless delay in treatment of the
C. Excisional biopsy malignancy. Cryotherapy is not an acceptable treatment for
D. Laser vaporization of the lesion squamous cancer of the vulva.
E. Cryotherapy
56. A 74-year-old G2P2 post-menopausal woman presents for a E. The finding of a mass in the Bartholin gland is highly suspicious
health maintenance examination. She notes the new onset of for malignancy and requires excision/biopsy, especially in a post-
a lump in her vagina, but denies any pain, abnormal bleeding menopausal women. Primary vulvar adenocarcinomas most likely
or vaginal discharge. She has well-controlled diabetes arise from the Bartholin gland, but other histologies such as
mellitus and hypertension. She is recently sexually active squamous cell, transitional, adenosquamous, and adenoid cystic
with a new partner since the death of her husband three carcinomas can also arise from this location. This is unlikely to be a
years ago. She smokes a half-pack per day, and has done so fibroma or lipoma given the recent onset and fixed nature of the
since age 18. On examination, she is noted to have a mass. A benign Bartholin gland cyst is also unlikely given the
somewhat firm and fixed non-tender 4 cm mass in her labia patient's age and rather abrupt onset, and any finding of a new
majora at the level of the Bartholin gland on the right. There Bartholin gland cyst in a post-menopausal woman should be further
is no associated erythema or discharge, and the remaining investigated. For any woman over the age of 40 with a mass in this
vulvar exam and pelvic exam are unremarkable. Her groin area, a biopsy should be obtained. This is not an abscess given the
examination reveals no adenopathy. What is the most likely absence of signs and symptoms of cellulitis or infection.
diagnosis?
A. Lipoma
B. Fibroma
C. Bartholin gland cyst
D. Bartholin gland abscess
E. Bartholin gland malignancy
57. An 81-year-old G3P3 presents to your office with a history of B. Postmenopausal bleeding or discharge accounts for the
light vaginal spotting. She states this has occurred recently presenting symptom in 80-90% of women with endometrial cancer.
and in association with a thin yellow discharge. She never However, the most common causes of postmenopausal bleeding
experienced any vaginal bleeding since menopause at the are atrophy of the endometrium (60-80%), hormone replacement
age of 52, and denies ever having been on hormone therapy (15-25%), endometrial cancer (10-15%), polyps (2-12%), and
replacement therapy. She is otherwise reasonably healthy, hyperplasia (5-10%). Any history of vaginal bleeding requires a
except for osteoporosis, well-controlled hypertension, and thorough history, physical/pelvic examination, and assessment of
diabetes. She is physically active and still drives to all her the endometrium. This is ideally done via office endometrial
appointments. She is no longer sexually active since the sampling as part of the initial work-up. The use of pelvic
death of her husband two years ago. On examination, she is transvaginal ultrasound can provide useful information as to the
noted to have severe atrophic changes affecting her vulva presence of any structural changes (polyps, myomas, endometrial
and vagina. A small Pederson speculum allows for thickening), and for which a diagnosis of endometrial cancer would
visualization of a normal multiparous cervix, and the be less likely if the endometrial thickness is < 5 mm. Although this
bimanual examination is notable for a small, mobile uterus. patient is likely to have atrophy as the cause of her spotting, a thin
Rectovaginal exam confirms no suspicious adnexal masses or endometrial stripe does not exclude the possibility of a non-
nodularity. Which of the following is the most appropriate estrogen dependent carcinoma of the atrophic endometrium.
management for this patient? Vaginal estrogen or clindamycin are not indicated.
A. Pelvic transvaginal ultrasound
B. Office endometrial biopsy
C. Reassurance and observation for further bleeding
D. Vaginal estrogen therapy
E. Clindamycin vaginal cream
58. An 88-year-old G2P2 woman is brought in for evaluation of blood found C. The most important step is to first biopsy the lesion.
in her diapers. She is a nursing home resident and has a long-standing It would be inappropriate to treat the lichen sclerosus
history of incontinence. This is the first time that her caregivers have first with steroids, as the lesion is suspicious for
noted blood. They describe it as "quarter size." Her nurses think that she malignancy. Treatment with benadryl would also be
may have been itching, as they frequently find her scratching through the inappropriate given the suspicious nature of the lesion.
diaper. On review of her medical record, biopsy-documented lichen Diagnostic studies such as cultures and cytology of
sclerosus of the vulva was diagnosed fifteen years ago. She has not been such a lesion are not appropriate given the exophytic,
on any therapy for this condition for years. Examination of the external nodular lesion seen on examination. A biopsy should
genitalia reveals an elevated, white, firm irregular lesion arising from the be performed to make a definitive diagnosis and rule
upper middle left labia. The lesion measures 2.5 cm in greatest dimension. out malignancy. It would also be inappropriate to treat
The remainder of the external genitalia shows evidence of excoriation of the patient with a vulvectomy and lymph node
thin, white skin with a wrinkled parchment appearance. The vagina and dissection before obtaining a clear diagnosis.
cervix are atrophic. No masses are noted on bimanual or rectovaginal
exam and a sample of her stool is negative for blood. No adenopathy is
noted in her groin. Which of the following is the most appropriate next
step in the management of this patient?
A. Begin topical steroids
B. Begin topical benadryl
C. Biopsy the lesion
D. Obtain cultures of the lesion
E. Complete vulvectomy and lymph node dissection
59. An 88-year-old woman is brought in for evaluation of blood found in her B. Squamous cell carcinoma accounts for
diapers. She is a nursing home resident and has a history of lichen approximately 90% of vulvar cancers. Patients
sclerosus of the vulva, which was diagnosed fifteen years ago. She quit commonly present with a lump and they commonly
smoking in her fifties. Examination of the external genitalia reveals an have a long-standing history of pruritus. The chronic
elevated, firm, erythematous, ulcerated lesion arising from the left labia, itch-scratch cycle of untreated lichen sclerosus, or any
measuring 2.5 cm in greatest dimension. What is the most likely diagnosis other chronic pruritic vulvar disease, is thought to
in this patient? stimulate the development of squamous carcinoma.
The mean age of squamous cell carcinoma is 65 years
A. Malignant melanoma and smoking is known to increase the risk of
B. Squamous cell carcinoma development of vulvar cancer, especially in the setting
C. Lichen sclerosus of HPV infection. With lichen sclerosus, the skin
D. Paget's disease appears thin, inelastic and white, with a "crinkled tissue
E. Verrucous carcinoma paper" appearance. Paget's disease of the vulva is
associated with white plaque-like lesions and poorly
demarcated erythema, not a discrete mass. Verrucous
carcinoma has cauliflower-like lesions. Melanoma
typically presents as a pigmented lesion.
60. An obese 30-year-old G3P1 Asian woman undergoes an uncomplicated C. The incidence of molar pregnancy is approximately
dilation and curettage for a first-trimester miscarriage. Pathology reveals 1 per 1,500-2,000 pregnancies among Caucasians in the
a molar pregnancy. The patient's medical history is significant for chronic United States. There is a much higher incidence among
hypertension. She has a history of a previous uncomplicated term Asian women in the United States (1/800.) Molar
pregnancy, and termination of a pregnancy at 16 weeks gestation for pregnancy occurs more frequently in women less than
trisomy 18. What aspect of the patient's history places her at increased 20 or older than 40 years of age. The incidence is
risk for a molar pregnancy? higher in areas where people consume less beta-
carotene and folic acid. There is no known association
A. Obesity between molar pregnancy and obesity, a previous
B. Previous history of fetal aneuploidy history of fetal aneuploidy, chronic hypertension and
C. Asian race parity. The risk of having a molar pregnancy is
D. Chronic hypertension increased in women with two or more miscarriages.
E. Prior term pregnancy
Unit 7: Violence against women
Study online at quizlet.com/_2isg3p
1. A 3-year-old girl is taken to see her primary care physician by her father, B. Yeast infections are common after antibiotic
secondary to vaginal discharge and swelling of the vulvar area for the past therapy. Scratching can appear like abuse is taking
week. She has been scratching the area and says it hurts. She was on an place. To examine a child, even with a nasal
antibiotic two weeks ago for an ear infection. The child has had normal speculum, is traumatic. If a foreign body is suspected,
growth and development. She has two male siblings, ages 8 and 6. Her an exam under anesthesia may be necessary, if
father is a stay-at-home dad and her mother is an attorney. Examination ultrasound is not successful or indicated.
reveals a red and swollen vulva with linear abrasions over the area. Which
of the following is the most appropriate next step in treatment?
A. Check a complete blood count
B. Begin antifungal treatment
C. Perform nasal speculum vaginal examination
D. Refuse to treat until mother is present
E. Notify police
2. A 4-year-old girl is taken to see her pediatrician by her father. He states B. Children will often place foreign objects in any
that he has noticed a foul odor in the area of the child's "private parts." He body orifice. Toilet paper is the most common foreign
brings in a pair of panties with a brown-yellow stain that has a "funny body found.
smell." The girl is otherwise healthy. Which is the most likely cause of this
condition?
A. Child abuse
B. Foreign body
C. Yeast infection
D. Pinworm infection
E. Urinary tract infection
3. A 6-year-old girl in kindergarten has begun to bed-wet after having been B. Child abuse can happen in any circumstance. It is
toilet trained for three years. She has also been found "playing with herself" not always the "boyfriend" who commits such a crime.
for the past several weeks. In a private conversation the child states, "My Often the perpetrator is a "pillar of the community."
daddy has been playing with me down there." Which of the following is the The child must be able to talk in a safe environment,
most appropriate course of action at this time? certainly not in the presence of the person accused
A. Suggest family counseling of the deed.
B. Notify police
C. Speak with her kindergarten teacher
D. Speak with both parents and child together
E. Admit the child to the hospital
4. A 10-year-old girl has been drawing sexually explicit pictures during art D. Children who are sexually abused will often "act
class. Her behavior in class has ranged from being shy to being aggressive out" and behave inappropriately. There is often no
with her fellow students. She won't go to the bathroom unless someone evidence of physical injury and a careful history must
goes with her. Physical examination shows a normally developed girl. Breast be taken. Asperger's syndrome is an autism spectrum
budding is occurring and she has wisps of axillary and pubic hair. She will disorder in which problems with social interaction
not let you "look at her bottom." Which of the following is the most likely occur and may include physical clumsiness and
cause of this condition? atypical use of language. Symptoms of childhood
A. Normal adolescent development depression may be similar to those seen in adult
B. Asperger's syndrome depression.
C. Precocious puberty
D. Child abuse
E. Childhood depression
5. A 17-year-old G0 was kissing her 18-year-old boyfriend in a parked car. She refused to C. Rape is characterized by lack of consent
have sexual intercourse and he overpowered her, hit her on the face and raped her. He or inability to give consent. Most
did not use a condom and ejaculated inside her. Which of the following made this case definitions include the use of physical
a rape? force, deception, intimidation or the threat
A. Failure to use effective barrier contraception of bodily harm.
B. Sexual intercourse
C. Lack of consent
D. Legal age of the woman
E. Legal age of the boyfriend
6. An 18-year-old college student is brought to your office by her roommate who found C. In a case of date rape, the best course
her sobbing in their room. The student states that she was sitting on a couch with her of action is to ensure that the patient does
new boyfriend. He gave her something to drink. She thinks that she passed out and not get pregnant. The patient should also
awoke two hours later and was undressed. She is afraid that she may have had have screening for sexually transmitted
intercourse. She is not on any form of contraceptive. Her last menstrual period was diseases, with consideration to being
two weeks ago. Examination reveals no obvious injuries and a vaginal swab shows offered antibiotic prophylaxis. Although
motile sperm. In addition to providing counseling and screening for sexually the risk of infection is unknown among
transmitted infections, which of the following is the most appropriate next step in victims of sexual assault, it may be higher
management? compared to consensual sexual
A. Discuss her responsibility to report this to her college encounters.
B. Admit to the hospital for intravenous antibiotics
C. Recommend emergency contraception
D. Notify her college advisor
E. Obtain more information from her roommate
7. An 18-year-old college student is seen in the emergency room, claiming she was B. Women who are raped are often in
raped by a 29-year-old janitor in her dorm four hours ago. He threatened her with a denial or shock. A woman may shower
knife and she did not resist. She appears calm and has a flattened affect when the after an attack, destroying evidence in an
history is taken. Currently, she is sexually active with a fellow student and is taking attempt to deny what happened or to
birth control pills. The alleged attacker used a condom, which she helped him put on. "clean herself." She may blame herself for
The student is 5 feet 2 inches tall and weighs 110 pounds. She is a cheerleader for the the attack and feel she should have
college football team. Examination reveals no bruising and gynecologic examination resisted more.
reveals no apparent injuries. Which of the following statements is the most likely
explanation for this patient's presentation?
A. The attack was not emotionally traumatic
B. The student is in shock
C. The attack never happened
D. The student cooperated with the attacker
E. The student suffers from chronic depression
8. A 24-year-old woman comes to her physician for help with her B. Victims of domestic violence frequently present with
premenstrual syndrome symptoms. She complains of "not being herself" vague physical and emotional complaints that are
for three to four days before her period and has episodes of crying and consistent with PMS. Victims will rarely volunteer
irritability. She denies depressive symptoms and notes she is a stay-at- information on first physician encounters, but
home mother for her three children. After a complete history and subsequent visits give opportunities to offer resources
physical examination, the patient is prescribed a selective serotonin for assistance. It is the patient's choice as to whether she
reuptake inhibitor but, after three months, she returns as there is no would like to involve the police. Social work
change in her symptoms. Upon further discussion, the patient admits consultation, family counseling and relocation are all
that her husband has a bad temper at times. Physical examination is reasonable options that fall under the resources that
normal with the exception of some bruising on the patient's arms. She may be discussed with the patient, but must be arranged
claims that she fell and that she is often clumsy. Which of the following is at the patient's request and with her consent. Emergency
the most appropriate next step in the management of this patient? department evaluation or physchiatric consultation are
A. Report the injuries to the police not indicated at this point.
B. Offer domestic violence resources to the patient
C. Refer the patient for a psychiatric consultation
D. Refer the patient to the emergency department for further evaluation
E. Arrange to move her children to a home of a close friend or family
member
9. A 28-year-old G1P0 presents to the emergency room at 2 am stating B. Sexual trauma and vaginal lacerations can occur
that, while having sex with her husband, she started to have severe during consensual sexual behavior and do not
vaginal bleeding. She has minimal pain, but is concerned that the necessarily indicate sexual abuse. However, aggressive
bleeding won't stop. On examination, she is mildly anxious and appears sexual activity can result in serious injuries, especially if
embarrassed. Her vital signs are notable for a blood pressure of 118/62 mechanical or foreign objects are not safely used.
and pulse of 104. Her abdominal exam is benign, and her pelvic exam is Exploration and repair of this injury should be done in
notable for a laceration along the posterior vaginal wall extending into the operating room under general anesthesia. A blood
the fornix. Active bleeding is occurring. When further questioned, she transfusion may be indicated, depending on her blood
admitted to using a new sexual toy that she and her husband wanted to count and estimated blood loss, but may not be
try out during intercourse. Which of the following is the most necessary. Testing and treatment for sexually transmitted
appropriate next step in management? infections or emergency contraception should be
A. Transfuse the patient with packed red blood cells immediately discussed with the patient, as not all cases of sexual
B. Repair the laceration under anesthesia trauma are due to abuse/assault.
C. Obtain cultures for sexually transmitted infections
D. Provide emergency contraception
E. Notify the police
10. A 30-year-old G2P2 was raped by a stranger while she was walking C. Antibiotic prophylaxis should be offered to all adult
through a park alone at 2:00 am. The assailant did not use a condom. An rape victims. Although patients are often reticent to do
intern evaluated the patient in the emergency room. He took a detailed so, they should be gently encouraged to work with the
history, performed a complete physical exam and collected forensic police. This has been associated with improved
specimens. He obtained cultures for gonorrhea and chlamydia, and emotional outcomes for victims. Counseling the patient
obtained an RPR, hepatitis antigens, an HIV test, a urinalysis and culture, regarding the practice of "safe behavior" at this time may
and a pregnancy test. He provided the patient with postcoital make the patient feel blame, when the blame should be
contraceptive medication. Which of the following additional actions is placed on the rapist. HSV antibody testing is not
most appropriate? indicated.
A. Notify police
B. Notify the patient's parents or her closest relative or friend
C. Offer the patient antibiotic prophylaxis for sexually transmitted
infections
D. Counsel the patient regarding the practice of "safe behavior,"
including not walking in deserted areas alone
E. Offer the patient testing for herpes simplex virus (HSV)
11. A 35-year-old woman presents for a health maintenance examination. She is present D. Domestic violence does not always have
with her husband who appears to be over-bearing and answers all the questions for to manifest in physical abuse.
her. She defers to him without resistance. During the examination, he gladly leaves the Disagreements and arguments, even
room. Her examination is entirely normal without any signs of bruising, trauma, or heated discussions, are part of a normal
injuries. When you ask her if she is in a relationship with a person who threatens or relationship. However, physical violence or
physically hurts her, she denies this and quickly dresses and leaves the exam room to other abusive behaviors are not. Signs of
meet her husband who is waiting for her outside the room prior to checking out. The being involved in an abusive relationship
following month, she returns again for an appointment alone to discuss "private may come in several forms and screening
matters." She is worried that her husband will leave her if she refuses to have sex with all women at routine ob-gyn visits, during
him even though she doesn't want to, and states he gets angry easily and throws family visits and during preconception
things. She loves him dearly and admits that they do have frequent disagreements, visits are recommended by the American
but he has never hit her. She is worried that he might find out that she is seeing the College of Ob-Gyn (ACOG). For the
doctor alone, and had to sneak out without him knowing. Which of the following is pregnant woman, screening should occur
LEAST likely to be a sign that she is in an abusive relationship? at the first prenatal visit, at least once per
A. Being frightened by threats of violence trimester, and at the postpartum checkup.
B. Having objects thrown by partner when angry
C. Being restricted from contacting family or friends
D. Having frequent disagreements
E. Having sex when not wanting to
12. A 79-year-old woman is seen in the emergency room in a comatose state. Her A. In a case of obvious elderly abuse,
daughter states that her mother is always wandering away from the home. She has social services must be notified. Physicians
tried to tie her to her bed, but has found that if she gives her zolpidem (Ambien) must be aware of the social services
every four hours, it keeps her sedated. The daughter works during the day and would available for their patients. The patient
put her mother in a nursing home, but she needs the mother's social security check to should not be taking zolpidem, and this
maintain the household. Examination reveals an unresponsive, thin, dehydrated should also be discontinued. The patient
woman with acute and chronic bedsores. After hydration and treatment of her skin may ultimately be discharged home or
condition in the hospital, which of the following is the most appropriate next step? possibly to a skilled nursing facility,
A. Notify social services depending on her needs, which should be
B. Notify hospital security done in consultation with social services
C. Discharge patient to hospice and discharge planning. At this time,
D. Consult psychiatry hospice or consultation with psychiatry are
E. Decrease the zolpidem dose not indicated.
13. An 84-year-old woman is seen in the emergency department because of a pain in her B
right arm. She is widowed and lives with her daughter, who states that her mother is
"always falling down" and is becoming forgetful. She would put her in a nursing home,
but her mother's social security check is needed for family expenses. She has a
history of breast cancer treated by mastectomy 15 years ago, and took tamoxifen for
five years. The patient is on zolpidem (Ambien) 10 mg for sleep. She has been unable
to afford the bisphosphonates needed for bone loss. Examination reveals a cachectic
white woman, 5 feet 2 inches tall, weighing 94 pounds. She has tenderness in her right
forearm with swelling. She is also noted to have old and new bruises on her chest and
arms. An x-ray of the right arm reveals a spiral fracture. Which of the following is the
most likely cause of the bone fracture?
A. Osteoporosis
B. Elder abuse
C. Bone metastasis from occult breast cancer
D. Malnutrition
E. Falls due to unsteadiness
14. A mother brings in her 6-year-old daughter for an examination. She states that she B. In all suspected cases of child abuse, the
thinks her boyfriend may be "fooling around" with the child. The girl runs and proper authorities must be notified. Often
hides when the boyfriend comes to their home. Examination reveals a normal 6- victims of child abuse have no physical
year-old girl. There is no evidence of sexual abuse. The mother wants nothing findings. Colposcopic examination is often
done as she is dependent on her boyfriend for support. Which of the following is inconclusive. The child may be acting out, but
the most appropriate course of action? it is better to err on the side of safety.
A. Advise return visit in one month
B. Notify police
C. Advise family counseling
D. Inform mother that the child may be jealous
E. Perform colposcopic examination
15. A representative from a domestic violence outreach program asks for your help in C. The best place to have literature is where
distributing information, to include a hot line to call, if needed. Where is the best there is the most privacy such as an office
place for this information to be made available? restroom. In the other areas cited, an abuser
A. Office waiting room may see the information and prevent his/her
B. Distribution to all patients at time of check in spouse or partner from obtaining it.
C. Office restroom
D. Letters sent to all your patients
E. Posters in front of your office