NOTCHTOP 2023 Flashcards

Question

Which of the following is referred to as mature cystic teratomas? A. Dermoid cyst B. Granulosa cell tumor C. Hilus cell tumor D. Thecoma

Answer 1

A. Dermoid cyst >Benign (Mature) Cystic Teratoma – also known as dermoid cyst, is the most common type of germ cell tumor, accounting for 25% of all ovarian neoplasms. Teratomas have the ability to produce adult tissue (skin, bone, teeth, hair, and dermal tissue). >Granulosa cell tumor – tumor consisting of primarily granulosa cells and a varying portion of theca cells, fibroblasts, or both. Histologically, they demonstrate Call- Exner bodies (eosinophilic bodies surrounded by granulosa cells). Produce increased levels of estrogen, present with uterine bleeding, and associated with endometrial hyperplasia that may lead to endometrial carcinoma. >Hilus cell tumor – these tumors occur after menopause and best managed by bilateral salpingo- oophorectomy and total abdominal hysterectomy >Thecoma – benign tumor that consists entirely of stroma (theca) cells. Associated with estrogen production but not as often as granulosa cell tumors.

Answer 2

B. In women under 35 years old, infertility is the inability to conceive after 12 months of unprotected intercourse By definition, infertility is the inability of a couple to conceive after 1 year of trying. For women older than 35 years old, the timeline should be after 6 months of trying (Choice A, C). Early investigation is also warranted if any of the following are present: oligomenorrhea or amenorrhea, known tubal obstruction, uterine disease, or known male factor infertility

Answer 3

A. Footling breech ● Breech presentation occurs in 2-3% of singleton pregnancies. Complete breech is when the hips are flexed and one or both knees are flexed. Incomplete or footling breech is when one or both of the hips are extended. Frank breech is when hips are flexed and knees are extended. ● Incomplete or footling breech has the highest risk of cord prolapse at 15% to 18% (Choice A), followed by complete breech at 4% to 6% (Choice C), and frank breech at 0.5% (Choice B).

Answer 4

D. Having an HBsAg (+) sex partner ● Those with a positive hepatitis B surface antigen (HBsAg test) are likely to have acute disease and are at risk for transmission (Choice D) ● Although the absence prenatal care (Choice C) and a history of previous home delivery (Choice A) would indicate that the patient was not screened for Hepatitis B in the past, it does not necessarily increase her risk for acquiring the infection. Having an uncircumcised sex partner (Choice B) has no known increased risk of acquiring Hepatitis B infection.

Answer 5

A. 10% potassium hydroxide Recall that Gardnerella vaginalis is one of the increased vaginal flora in patients with bacterial vaginosis (see item #12). Diagnosis of bacterial vaginosis can be made using Amsel criteria, which requires that 3 out of 4 criteria are present: (1) presence of thin, white, homogenous discharge coating the vaginal walls (2) an amine odor noted with addition of 10% KOH (3) pH > 4.5 (4) presence of >20% of clue cells on microscopic examination.

Answer 6

C. Functional weight-bearing exercise ● Weight-bearing exercise (such as walking, hiking, and stair- climbing) and muscle-strengthening exercise have been found to decrease the risk of falls and fractures. This can be explained by Wolff's Law where bones will adapt based on the stress or demands placed on them. ● Although water aerobics (Choice A), ballroom dancing (Choice B), and indoor cycling (Choice D), can be recommended, the most benefit to decrease risk of fractures would be functional weight-bearing exercises.

Answer 7

C. INEVITABLE ABORTION ● Inevitable abortion – no expulsion of any products of conception but with vaginal bleeding and dilation of the cervix such that maintaining pregnancy is unlikely, (+) cervical dilation, (+/-) fetal heart tones ● Threatened abortion – any bleeding < 20 weeks AOG, (-) cervical dilation, (-) expulsion of any products of conception, (+) fetal heart tones ● Missed abortion - dead products of conception have been retained for days or weeks, (-) cervical dilation, (-) fetal heart tones ● Incomplete abortion – partial expulsion of some, but not all products of conception in <20 weeks AOG, (+) cervical dilation, (-) fetal heart tones ● Complete abortion – complete expulsion of all products of conception in < 20 weeks AOG, closed cervix, no fetal heart tones

Answer 8

A. Less than or equal to 95 mg/dl ● Glucose targets for pregnant women include: o FBS <95 mg/dL (5.3 mmol/L) o 1 hour post-prandial glucose <140 mg/dL (7.8 mmol/L) (Choice C) o 2 hours post-prandial glucose <120 mg/dL (6.7 mmol/L) (Choice B) ● Diagnosis of gestational diabetes mellitus (IADPSG Recommendations) o FBS > 92 mg/dL o 1 hour 75g OGTT >180 mg/dL (Choice D) o 2 hour 75g OGTT >153 mg/dL

Answer 9

C. Nucleic acid amplification test ● Screening for gonorrhea in women is by culture or nucleic acid amplification (NAAT). NAATs have replaced culture in most laboratories and kits are available for specific collection from the vagina, endocervix, or urine. ● NAAT of the urine or vaginal secretions are over 95% sensitive and specific and are the most sensitive and specific diagnostic tool for identifying gonorrheal infections. ● Culture and sensitivity (Choice A) can be done but it will take days before a diagnosis will be made. Gram staining (Choice B) can identify presence of gram-negative intracellular diplococci and polymorhpnuclear leukocytes but is not the gold standard. Pap smear (Choice C) will not be able to identify the specific etiologic agent as compared to NAAT.

Answer 10

D. Shoulder dystocia ● Fetal macrosomia describes fetuses whose estimated weight exceeds a threshold of >4000-5000g. Macrosomic fetuses have a higher risk of shoulder dystocia, obstetrical brachial plexus injuries, and birth fractures. ● Although there is a higher rate of cesarean delivery in women with macrosomic fetuses due to failure to progress in labor (Choice C), shoulder dystocia is more common. ● Cord prolapse (Choice A) is associated more with fooling breech presentation. Hypertonic uterine contraction (Choice B) is associated with high concentrations of oxytocin.

Answer 11

B. THEY CAN BEGIN SEVERAL YEARS BEFORE ACTUAL MENOPAUSE ● In Filipina women, the average age of menopause is 47-48. Subtle changes in endocrine and menstrual function can occur for up to 3 years before menopause (Choice B). ● Hot flushes usually occur for 2 years after the onset of estrogen deficiency but can persist for more that 10 years which may cause irritability and affect quality of life (Choice A, D). ● The earliest sign of impending menopause is a change change in menstrual length (Choice C).

Answer 12

C. Quickening ● Quickening – maternal perception of fetal movement. o For primigravid, at 18-20 weeks o For multigravidas, 16-18 weeks ● Softening (Choice A) – initial stage of cervical remodeling that begins during phase 1 of parturition

Answer 13

D. Progestin If a woman wants to undergo HRT and has an intact uterus, she must have progesterone with estrogen to protect her uterus from endometrial hyperplasia or malignancy. If estrogen alone is used, it will cause the endometrial lining to grow while progesterone will stabilize the lining from proliferating abnormally.

Answer 14

C. Bilateral tubal ligation ● Bilateral tubal ligation – permanent sterilization involving surgical occlusion of both fallopian tubes to prevent the ovum and sperm from uniting. ● Combined oral contraceptives (Choice A) interfere with the pulsatile release of FSH and LH from the anterior pituitary. This ‘pseudopregnancy’ state suppresses ovulation and prevents pregnancy from occurring. ● Implanon (Choice B) or subdermal progestin implant – reversible contraceptive method that can provide 3 years of uninterrupted contraceptive coverage it acts by suppressing ovulation, altering the endometrium, and thickening cervical mucus ● Vasectomy (Choice D) – permanent sterilization for males involving ligation of the vas deferens. However, it is important to note that vasectomy is not immediately effective because sperm can remain viable in the proximal collecting system after the procedure. Therefore, additional contraception should still be used up to 6-8 weeks.

Answer 15

A. Nonoxynol-9 ● Most spermicides contain nonoxynol-9 and are sold over the counter as creams, jellies, suppositories, films, and foams. ● They provide a chemical spermicidal action and a physical barrier to sperm penetration.

Answer 16

D. Low folic acid intake ● Risk factors for ectopic pregnancy include: o History of STIs or PID (Choice B) o Prior ectopic pregnancy o Previous tubal surgery o Prior pelvic or abdominal surgery resulting in adhesions (Choice C) o Endometriosis o Current use of exogenous hormones o IVF or assisted reproductive technologies (Choice A) o DES-exposed patients with congenital abnormalities o use of IUD for birth control o Smoking ● Low folic acid intake is associated more with neural tube defects. Leucovorin (Folinic acid) is used in the management of ectopic pregnancies, where is it added to medical therapies. It has folic acid activity that allows purine and pyrimidine synthesis to buffer side effects.

Answer 17

D. Skin of the vulva Granuloma inguinale (Donovanosis) is a chronic, ulcerative, bacterial infection of the skin and subcutaneous tissue of the vulva. Spread is through both sexual and close non-sexual contact. Etiologic agent is Klebsiella granulomatis. It presents as a painless, slowly progressing ulcer surrounded by granulation tissue.

Answer 18

C. Mitral stenosis Rheumatic endocarditis causes most mitral stenosis lesions. In pregnancies complicated by rheumatic heart disease (predominantly mitral stenosis) 8 of 10 maternal deaths were in women in NYHA classes III or IV.

Answer 19

D. Cefazolin 2g IV According to the National Antibiotic Guidelines (2018), for Cesarean section – Cefazolin 2g IV. Alternative treatment: Clindamycin 900mg IV PLUS Gentamicin 5mg/kg IV x 1 dose.

Answer 20

A. FSH levels are higher in hypergonadotropic hypogonadism Ratio: ● (-) breasts and (+) uterus – FSH will differentiate between hypergonadotropic and hypogonadotropic hypogonadism. ● Hypergonadotropic hypogonadism is failure of gonadal development and it is the most common cause of primary amenorrhea. Absent ovarian follicles mean that synthesis of ovarian steroids and inhibin does not occur, therefore, breast development does not occur (low estrogen). Gonadotropin levels (FSH, LH) are elevated due to negative feedback. FSH is higher than LH (Choice C). ● Hypogonadotropic hypogonadism is due to a primary hypothalamic problem where there is insufficient GnRH synthesis. Since there is low GnRH, gonadotropin levels

Answer 21

C. GnRH agonist ● GnRH agonists (Leuprolide) lead to a hypoestrogenic state by suppression of the hypothalamic-pituitary axis. This induces a state of amenorrhea to control the pain and bleeding from adenomyosis. Definitive management is hysterectomy. ● Tamoxifen (Choice A) is a selective estrogen receptor modulator (SERM) medication used in the treatment of breast cancer. Estrogen (Choice B) is used as part of the Hormonal Replacement Therapy in post-menopausal women. Cyproterone acetate (Choice D) is used in combination with ethinyl estradiol to treat women with severe acne and symptoms of androgenization.

Answer 22

B. Skin dermatosis ● Among the choices, only skin dermatosis currently has no known correlation to amenorrhea. ● Milky discharge or galactorrhea (Choice A) may be associated with excess prolactin levels. Severe headache (Choice D) may indicate a tumor such as in prolactinomas. Excess facial hair (Choice C) is a sign of hyperandrogenism.

Answer 23

D. Oxytocin ● Beta-adrenergic agonists, magnesium sulfate (Choice A), calcium-channel blockers, or indomethacin are the recommended tocolytic agents for short-term use. o Terbutaline (Beta-adrenergic agonist)[Choice B] o Nifedipine (Calcium channel blocker) [Choice C] ● Oxytocin (Choice D) is used to augment labor.

Answer 24

A. Primidone ● Primidone – first-generation antiepileptic drug. Primidone is not a prodrug and is active by itself. Active metabolites include (1) phenyl-ethyl-malonamide and (2) phenobarbital. ● Primidone, Phenytoin (Choice B), Valproic acid (Choice D) are anti-epileptic drug that are teratogenic. Primidone and phenytoin act as folate antagonists leading to increased risk neural tube defects. ● Topiramate (Choice C) is known to reduce efficacy of oral contraceptives.

Answer 25

A. Braxton hicks ● Braxton Hicks – occasional irregular contractions that do not lead to cervical change ● Montevideo units (Choice B) are calculated by subtracting the baseline uterine pressure from the peak contraction pressure for each contraction in a 10-minute window and adding the pressures generated by each contraction. ● Hypertonic uterus (Choice C) – is a uterine dysfunction wherein basal tone is elevated appreciably or the pressure gradient is distorted. ● Hypotonic uterus (Choice D) – is a uterine dysfunction where basal tone is normal and uterine contractions are synchronous but pressure during contraction is insufficient to dilate the cervix

Answer 26

C. Perineum The most common lacerations are perineal lacerations, which are described by the depth of tissues they involve. Cervical lacerations (Choice A) are also seen in vaginal deliveries and may be a source of post-partum bleeding. Lacerations on the labia majora (Choice B) and periurethral area (Choice D) are not as commonly seen.

Answer 27

D. Hyaline membrane disease Ratio: ● Prematurity immediately puts infants at increased risk of respiratory distress syndrome (hyaline membrane disease), intraventricular hemorrhage, sepsis, and necrotizing enterocolitis. ● Adrenal insufficiency (Choice A) and Myocardial ischemia (Choice B) are not known to be a fetal complication of preterm labor. Neonatal pneumonia (Choice C) may occur in preterm infants but not as common as hyaline membrane disease.

Answer 28

D. Spina bifida ● Spina bifida is a neural tube defect and has classic ultrasound findings of “lemon” sign (concave frontal bones) and “banana” sign (cerebellum pulled caudally and flattened). ● Down syndrome (Choice A) – associated with low maternal serum AFP and estriol and elevated B-hCG and inhibin. Notable ultrasound finding is echogenic intracardiac focus. ● Klinefelter syndrome (Choice B) – is caused by sex chromosome aneuploidy with symptoms of infertility, gynecomastia, mental retardation, and elevated gonadotropin levels. ● Potter syndrome (Choice D) -- results from renal failure leading to anhydramnios, which in turn causes pulmonary hypoplasia and contractures or deformations of the limbs in the fetus

Answer 29

A. INFECTIONS AFTER DELIVERY DEVELOP IN 20% OF PATIENTS WHO UNDERWENT EPISIOTOMIES ● Episiotomy infections are classically reported as being rare at a rate of 0.1% and increasing up to 2% if a third- or fourth- degree tear occurs. ● Episiotomy infections present with increasing pain, discharge, edema, and systemic symptoms of infection (Choice B). Local erythema and tenderness over the site are the most common physical signs (Choice D). Antibiotics with coverage against staphylococci, streptococci, enteric, and anaerobic organisms should be considered in treatment (Choice C).

Answer 30

B. Prolapse of umbilical cord ● Incomplete or footling breech has the highest risk of cord prolapse at 15% to 18%, followed by complete breech at 4% to 6%, and frank breech at 0.5%. Acute asphyxia from compression of the umbilical cord can occur. ● Prematurity (Choice A) is associated with increased risk of respiratory distress syndrome. Although oligohydramnios (Choice C) is associated with cord prolapse leading to asphyxia, it is not always present with incomplete breech presentations. Cerebral palsy (Choice D) is a result of asphyxia during childbirth.

Answer 31

B. Pyrethrins with piperonyl butoxide ● Treatment of pediculosis pubis includes permethrin 1% cream rinse applied to the affected areas and washed off after 10 minutes or pyrethrins with piperonyl butoxide applied to the affected area and washed off after 10 minutes. ● Metronidazole, Amoxicillin, or Trimethoprim sulfamethoxazole (Choice A, C) are antibiotics and will not be effective on pediculosis pubis since it is not a bacterial infection. 5-flurouracil cream (Choice D) is used in the treatment of pre-cancerous and cancerous skin lesions.

Answer 32

A. 1 year or more prior to pregnancy Ratio: Patients who would benefit surgical repair of a lesion as in mitral or aortic stenosis should undergo surgical repair a year.

Answer 33

D. None of the above All of the choices are considered benefits of family planning. Benefits of family planning include: 1) reduction of pregnancy-associated complications, adolescent pregnancies, and infant mortality rates 2) prevention of sexually transmitted infections, and 3) increasing awareness on contraception and safe sex practices.

Answer 34

C. 4.8 to 8.4 ng/ml Loss of patellar reflexes >9 Respiratory paralysis >12 Cardiac arrest >30

Answer 35

A. A persistent occiput transverse is more common with android pelvis ● A persistent occiput transverse position leading to arrest of labor is more common in women with a platypelloid pelvis. ● If the second stage of labor is prolonged, the options include delivery of the fetus with forceps or vacuum in the occiput posterior position (Choice B), rotation with forceps, or manual rotation. ● During descent, occiput posterior positions may rotate to occiput anterior, although this does not always occur and can slow progress in labor (Choice C, D)

Answer 36

C. Between 11-13 weeks age of gestation First trimester screening for chromosomal abnormalities can be done at 11 to 14 weeks.

Answer 37

B. Ultrasound with doppler studies ● Any infant at risk for IUGR or being SGA is followed with serial ultrasound scans for growth every 2-3 weeks. Another test to differentiate IUGR fetuses is Doppler investigation of the umbilical artery. ● Amniocentesis (Choice A) and 4D Ultrasound (Choice D) wont be able to diagnose if there are any umbilical artery or placental problems that are causing the IUGR. MRI (Choice C) will help us visualize the soft tissue but is not first line.

Answer 38

B. MAGNESIUM SULFATE ● In pregnancy, magnesium sulfate is used for seizure prophylaxis. Phenobarbital (Choice A), Valproate (Choice C), and Carbamazepine (Choice D) have known teratogenic effects.

Answer 39

D. Propylthiouracil ● Patients with hyperthyroidism are managed with propylthiouracil (PTU) or methimazole, which decrease the production of the T4 (both) and block its peripheral conversion to T3 (PTU only). PTU is preferred in the first trimester and should be replaced by MMI after this trimester. ● Levothyroxine (Choice B) is used in hypothyroidism. ●Radioiodine with potassium iodine (Choice C) is contraindicated during pregnancy because it readily crosses the placenta and is concentrated in the fetal thyroid gland by 12 weeks’ gestation. ● Methimazole (Choice A) Methimazole has been associated with a 2-fold increased risk for aplasia cutis congenita, as well as choanal atresia and esophageal atresia

Answer 40

B. Hot flushes Among the choices, only hot flushes are a vasomotor symptom related to the thermoregulatory region of the brain. Patients classically present with irregular menses or amenorrhea, vasomotor symptoms (hot flushes), mood changes, depression or anxiety, insomnia, and vaginal dryness or dyspareunia, which may be associated with a loss of desire for sexual intimacy or activity.

Answer 41

A. Oral contraceptives Patients with decreased menstrual volume or hypomenorrhea have regularly timed menses but unusually light amount of flow. Patients on combined oral contraceptive pills, Depo-Provera, and the progestin-containing IUDs can have endometrial atrophy resulting in light menses.

Answer 42

D. Tension 4Ts of postpartum hemorrhage include: Thrombin, Trauma, Tone, Tissue

Answer 43

D. MMR Among the choices, only MMR is a live vaccine. Because of theoretical risk of transmission of the live virus in the vaccine, patients do not receive the measles, mumps, rubella (MMR) vaccine until postpartum, and patients are advised to avoid pregnancy for 1 month following vaccination

Answer 44

D. 5 Using the Bishop score o Cervical dilation 2 cm = 1 o Cervical effacement 40-50% = 1 o Cervical consistency medium = 1 o Cervical position mid-position = 1 o Fetal station -2 = 1

Answer 45

D. Consumptive coagulopathy Blood loss due to placental abruption is the most common cause of consumptive coagulopathy in obstetrics. In the setting of abruption, consumptive coagulopathy occurs due to activation of intravascular coagulation with varying degrees of defibrination. Likelihood of consumptive coagulopathy is also increase with concealed hemorrhage in patients with placental abruption. Although pulmonary failure (Choice A) and hypoxic encephalopathy (Choice B) can occur in cases of massive blood loss, consumptive coagulopathy is more commonly associated with placental abruption. Chronic tubular necrosis (Choice C) is less likely to occur since the blood loss is acute.

Answer 46

B. Estrogen Among the choices, only estrogen is epileptogenic, decreasing seizure threshold. Raised estrogen induces the activity of UGT enzymes considerably. UDP-glucuronosyltransferases are phase II drug-metabolizing enzymes that metabolize endogenous fatty acids and prescription drugs. Progesterone has an anti-epileptic effect.

Answer 47

A. 20-25% Despite careful management, HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome results in a high rate of stillbirth (10-15%) and neonatal death (20-25%).

Answer 48

D. All statements are true Most significant risk of PROM is the development of chorioamnionitis. (Choice A) Antibiotics are recommended for women with prolonged rupture of membranes and for women with unknown group B streptococcus (GBS) status. PROM can be diagnosed by visual inspection, nitrazine test, Aminisure test, or tampon test (Choice C).

Answer 49

B. Candidiasis ● Candidiasis (Choice B) – vaginitis presenting with thick, curdy discharge, dysuria, pruritus, and increased odor. ● Trichomoniasis (Choice A) – vaginitis presenting with yellow, frothy discharge, with or without vaginal or cervical erythema, increased odor, dysuria, and pruritus. ● Bacterial vaginosis (Choice C) – vaginitis presenting with thin, whitish gray, homogeneous discharge and increased odor ● Primary Syphilis (Choice D) – painless solitary ulcer found on the vulva vagina, or cervix with associated palpable inguinal lymph node

Answer 50

D. Erythromcyin Regimens recommended in the setting of PPROM: o Ampicillin with erythromycin (48 hours IV followed by 5 days of oral erythromycin and amoxicillin) o Azithromycin (oral) once and 48 hours of IV ampicillin

Answer 51

A. Estradiol ● FSH stimulates granulosa cells in the ovarian follicles to synthesize aromatase. Aromatase then converts androgens produced by the theca cells to estradiol. ● Estrone (Choice C) is the prominent estrogen during menopause an estriol (Choice B) during pregnancy.

Answer 52

A. BMI of 28 Endometrial cancer can be caused by prolonged exposure to excess endogenous estrogen without concomitant progesterone exposure – this is demonstrated in obese women because of peripheral conversion of androgens to estrone and estradiol in the adipocytes leading to increased levels of endogenous estrogen. Other choices are not known to be associated with endometrial cancer.

Answer 53

C. Endometrial biopsy Endometrial biopsy first-line test for evaluating endometrial pathology. It is up to 95% accurate and should be performed in all postmenopausal women with a thickened endometrial stripe (>4 mm) or with persistent vaginal bleeding.

Answer 54

C. Endometrial cancer ● Endometrial cancer – majority of patients with endometrial cancer present with abnormal vaginal bleeding. The cervix may be firm and expanded and the uterus may be normal size or enlarged. o Risk factors include unopposed estrogen exposure, obesity, nulliparity, late menopause, chronic anovulation, diabetes mellitus, cancer of the breast, ovary, or colon, family history of endometrial cancer and/or Lynch Syndrome. Additionally, the patient underwent fractional curettage which could point to an endometrial pathology. ● Ovarian CA (Choice A) is less likely since there were no adnexal mass or tenderness noted. Cervical CA (Choice D) is less likely since the cervix was grossly normal and no tenderness noted. Leiomyosarcoma (Choice B) can be considered as a differential given the enlarged corpus but the risk factors of the patient and past history of curettage point more toward endometrial CA.

Answer 55

B. Lynch syndrome ● Women with a known family history of Lynch II syndrome (HNPCC) are associated with a genetic predisposition to colorectal, endometrial, ovarian, kidney, stomach, and small bowel cancers. Other choices have not shown increased risk for endometrial CA.

Answer 56

B. Squamous cell carcinoma Squamous cell carcnioma accounts for 80-90% of all cervical cancers. Most SCCs occur in the transformation zone where the ectocervix meets the endocervix. The route of metastasis is most often by direct extension. Adenocarcinoma (Choice C) accounts for most of the remaining 10-20% cervical cancers.

Answer 57

C. Magnetic resonance imaging Diagnostic tools for staging of cervical cancer include examination under anesthesia (Choice A), chest x-ray, cystoscopy (Choice D), proctoscopy, intravenous pyelography (Choice B), and barium enema. ● MRI and CT may be used to define the extent of the disease but not used for staging.

Answer 58

C. II-A ● For easier recall, think about the general descriptions per stage o Stage I is confined to the cervix. o Stage II extends beyond the cervix, but does not extended to the lower third of the vagina or to the pelvic wall o Stage III involves the lower third of the vagina, and/or extends to the pelvic wall and/or causes hydronephrosis or nonfunctioning kidney and/or involves pelvic and/or para-aortic lymph nodes o Stage IV,extends beyond the true pelvis,invasion to local structures, including the bladder or rectum, or distant metastases. ● Next, the patient has a visible mass and only occupies the upper third of the vagina (not the lower third) without parametrial involvement, the patient has Stage II-A. o IIA - limited to the upper two-thirds of the vagina without parametrial involvement o IIB - with parametrial involvement but not up to the pelvic wall ● Next, the mass measures 1.5x 1.5. Patient is Stage IIA-1 o IIA-1 - Invasive carcinoma ≤4 cm in greatest dimension o IIA-2 - Invasive carcinoma >4 cm in greatest dimension ● See Chapter 18, Section II of OB Platinum or the TN Gyne main handout for the complete staging of cervical cancer

Answer 59

B. Radical hysterectomy According to FIGO, IIA1 cervical cancer, surgery or radiotherapy can be chosen as the primary treatment depending on other patient factors and local resources, as both have similar outcomes. Type C radical hysterectomy is the standard procedure for the treatment of cervical cancer, consisting of removal of the uterus, parametrium, upper vagina, and a part of the paracolpium, along with pelvic lymphadenectomy.

Answer 60

D. HPV Testing Majority of cervical cancers are due to human papilloma virus (HPV). Screening using pap smear and HPV testing can be done to assess possible risk of developing cervical cancer. HPV testing is recommended that women with an ASC-US result be tested immediately for presence of high-risk HPV subtypes (reflex testing). Blood CEA, Colposcopy, and transvaginal ultrasound are not known to identify risk of cervical concern in women.

Answer 61

C. Pelvic inflammatory disease PID is strongly associated with infertility. Specifically, infertility risk increases with the number of PID episodes: 12% with one episode, 20% with two episodes, and 40% with three or more episodes.

Answer 62

B. 20% Each month that she tries, a healthy fertile 30-year-old woman has a 20% chance of getting pregnant.

Answer 63

The primary tests for the evaluation of ovulatory factor infertility involve looking for evidence of ovulation by tracking the menstrual cycle. Endocrine evaluation may include measurements of FSH, LH, PRL, TFTs, and TRAbs.

Answer 64

A. 20% Contribution of male and femal factors to infertility o 35% male factor only o 45-55% female factor only ▪ 32% ovulatory disorders, 34% fallopian tube abnormalities, 15% endometriosis o 10% unexplained infertility o 10-20% combination male and female factors

Answer 65

D. PATIENT SHOULD BE SEATED WHEN BLOOD PRESSURE IS TAKEN ON 2 OCCASIONS 4-6 HOURS APART ● BP should be evaluated while the patient is in a seated position because when patients lie in the supine position on their side, this lowers their BP. ● Choice A is incorrect because BP measurement can be kept in a BP diary and shown every prenatal visit. It is important that the patient knows what values would indicate an emergency. Choice B is incorrect because laying in left lateral decubitus position prior to measurement is not a requirement. Although, this position provides relief to pregnant patients because it displaces the uterus from the inferior vena cava. Choice C is incorrect because although deep breathing can help in relaxing the patient, it is not a requirement prior to measurement.

Answer 66

C. Preeclampsia without severe features ● Preeclampsia o New-onset BP elevations (SBP >140, DBP >90, or both) >20 weeks of gestation with proteinuria (>300 mg per 24- hour urine collection), or protein:creatinine ratio >0.3, or urine dipstick reading > + 1, OR o In the absence of proteinuria, new onset hypertension with new onset of any of the following: Impaired liver function (2x elevation of liver transaminases), Persistent cerebral/visual symptoms (headache, blurring of vision), Pulmonary edema, Renal insufficiency (creatinine 97 μmol/L or 1.1 mg/dL or doubling of creatinine in the absence of renal disease), Thrombocytopenia ● Preeclampsia with severe features o SBP >160, DBP >110, or both on 2 occasions at least 4 hours apart while a patient is on bed rest o Impaired liver function (2x elevation of liver transaminases) o Persistent cerebral/visual symptoms (headache, blurring of vision) o Pulmonary edema o Renal insufficiency (creatinine 97 μmol/L or 1.1 mg/dL or doubling of creatinine in the absence of renal disease) o Thrombocytopenia (platelet count <100,000 umol/L)

Answer 67

D. Urine protein

Answer 68

B. First degree relative with preeclampsia Risk factors for preeclampsia: maternal age (<20 or >30), nulliparity, previous preeclampsia, multiple gestation, abnormal placentation, new paternity, and family history (Choice B). Other choices are not known to be risk factors for preeclampsia.

Answer 69

A. 1 lb Recommended pregnancy weight gain: o Underweight and normal weight: 1 lb/week o Overweight: 0.6 lb/week o Obese 0.5 lb/week

Answer 70

C. CESAREAN SECTION SCAR ● Predisposing factors for placenta previa include prior cesarean section and uterine surgery, multiparity, multiple gestation, erythroblastosis, smoking, history of placenta previa, and increasing maternal age. Other choices are not known to be risk factors for placenta previa

Answer 71

A. INTERNAL EXAMINATION ● Vaginal examination is contraindicated in placenta previa because the digital examination can cause further separation of the placenta and trigger catastrophic hemorrhage. Leopold’s maneuver (Choice B), transrectal digital exam (Choice C), and transabdominal exam (Choice D) are considered safe in patients with placenta previa.

Answer 72

B. DEVELOPMENT OF LOWER UTERINE SEGMENT ● The first episode of bleeding (the “sentinel” bleed) usually occurs after 28 weeks of gestation. During this time, the lower uterine segment develops and thins, disrupting the placental attachment resulting in bleeding. ● Although, increasing volume in the uterus (Choice A) occurs normally in pregnancy and prostaglandins in the circulating fetal and maternal blood (Choice D) contribute to myometrial contractions, they are not known to lead to hemorrhage.. Braxton Hicks maneuvers (Choice C) do increase in frequency towards the end of pregnancy but not known to lead to hemorrhage as well

Answer 73

C. PLACENTA ACCRETA Placenta previa can be complicated by an associated placenta accreta in approximately 5% of cases.

Answer 74

C. POSTERIOR Women with anterior placentas have poorer prognostic factors and are more likely to have massive blood loss and higher hysterectomy rates compared to any other location. The anterior location, as compared to the other choices, predisposes it to complication especially later in pregnancy as the lower uterine segment develops.

Answer 75

C. CESAREAN DELIVERY A persistent occiput transverse position leading to arrest of labor is more common in women with a platypelloid pelvis. ● During descent, occiput posterior positions may rotate to occiput anterior, although this does not always occur and can slow progress in labor. This can lead to prolonged labor and higher rate of cesarean delivery. Thus, OT or OP position may be suspected with an abnormally long labor.

NOTCHTOP 2023 Flashcards

(100 cards)