OB/Gyn: UWorld Flashcards
(181 cards)
1
Q
What disorder is characterized by a patient with a blind ended vaginal pouch with little or no uterine tissue and a XX genotype?
A
Mullerian agenesis
The differential diagnosis for a patient with a female phenotype but lacking a normal vagina and uterus includes mulerian agenesis, androgen insensitivity, and 5-alpha-reductase deficiency. Of these, only mullerian agenesis is characterized by an XX genotype.
2
Q
What is the first-line medication for the treatment of hypertension in pregnancy?
A
Methyldopa
Methyldopa is a pregnancy category B agent.
3
Q
Patients with 47 XXY have what diagnosis?
A
Klinefelter’s syndrome
This is associated with male phenotype and small testes.
3
Q
Large genital warts (lesions) can be treated with what?
A
Excision or fulguration (electric current)
Regardless of the method of treatment, rates of recurrence are high.
4
Q
When is Trimethoprim-Sulfamethoxazole (TMP-SMX) permissible during pregnancy?
A
2nd trimester
4
Q
What happens to total T4 and TSH during pregnancy?
A
Total T4 increases but TSH stays the same
Increased estrogen during pregnancy leads to an increase in thyroid binding globulin (TBG) which results in an increase in TBG-bound T3 and T4. Thus total T4 and T3 are increased, but free T4 and T3 remain normal so TSH also remains normal.
5
Q
Congenital anomalies, congenital infections, and chromosomal abnormalities usually result in what kind of intrauterine growth restriction (IUGR)?
A
Symmetric IUGR
In symmetric IUGR, the insult to the fetus often begins before 28 weeks gestation, and growth of both the head and the body are similarly lagging behind dates.
5
Q
What should you suspect in a post-menopausal female with symptoms of vaginal dryness and dysuria, and physical exam findings of pale, dry vaginal mucosa, diminished labial fat pad, and scarce pubic hair?
A
Atrophic vaginitis
Moderate and severe cases require local estrogen therapy.
5
Q
An antepartum hemorrhage with fetal heart changes progressing from tachycardia to bradycardia and finally to a sinusoidal pattern occurring suddenly after rupture of membranes suggests the diagnosis of what?
A
Vasa previa
The bleeding in this setting is fetal in origin, so maternal vital signs will remain stable while the fetus exsanguinates. When this condition is diagnosed, the treatment is an immediate caesarian section delivery (crash c-section).
5
Q
Patients with what diagnosis present with primary amenorrhea and anosmia?
A
Kallmann’s syndrome
They have a normal female karyotype and will have laboratory findings consistent with GnRH deficiency (low FSH and LH).
6
Q
A finding of atypical squamous cells of undetermined significance on cytology in a patient aged between 21 and 24 years is managed how?
A
Repeat cytology in 1 year
In this young patient population, HPV infection is transient and malignant transformation is rare. For this reason, colposcopy is not performed unless the patient demonstrates ASC3 on 3 consecutive pap smears. However, colposcopy is recommended for any ASC-H, atypical glandular cells, or high-grade squamous intraepithelial lesion.
7
Q
What is characterized clinically by a fever and uterine tenderness in the postpartum period and is often associated with foul-smelling lochia
A
Endometritis
- Risk factors include prolonge rupture of membranes (ROM), prolonged labor, operative vaginal delivery, and C-section.*
- Broad spectrum antibiotics are required to treat this typically polymicrobial infection*.
8
Q
What presents similarly to mastitis but lacks a fever and systemic symptoms?
A
Plugged ducts
Treatment is by improving the quality of breastfeeding. Persistently plugged ducts resulting in a galactocele may be treated with aspiration.
8
Q
Female offspring of women who ingested diethylstilbestrol during pregnancy are at increased risk of developing what?
A
Clear cell adenocarcinoma of the vagina and cervix
As well as cervical anomalies (hypoplasia) and uterine malformations (T-shaped/small uterine cavity), vaginal adenosis, and vaginal septae. Many have difficulty conceiving and maintaining pregnancy.
9
Q
What pregnancy-associated disorder is characterized by markedly elevated alkaline phosphatase and cholesterol levels in conjunction with intense pruritis?
A
Primary biliary cirrhosis
9
Q
Multinucleated giant cells and a vesicular rash seen on genital exam are characteristic of what?
A
Genital herpes
10
Q
What is the treatment of choice for postpartum endometritis?
A
IV clindamycin and IV gentamicin
11
Q
In what phase of the menstrual cycle is cervical mucus thicker, less stretchable, and inhospitable to sperm?
A
The mid- and late-luteal phase
12
Q
What is the most commonly identified infectious agent associated with fetal growth restriction (FGR)?
A
Cytomegalovirus (CMV)
This can not be effectively prevented or treated in most cases.
13
Q
What causes gestational maternal virilization and virilization of XX fetuses leading to affected girls with normal internal genitalia with ambiguous external genitalia?
A
Congenital aromatase deficiency
Loss of peripheral conversion of androgens to estrogens.
13
Q
How many days after unprotected intercourse can levonorgestrel be given?
A
5 days (120 hours)
Levonorgestrel = Plan B
14
Q
Which vaginitis/vaginosis is characterized by inflammation, pruritus, and a thin malodorous vaginal discharge?
A
Trichomonas vaginitis
In contrast, bacterial vaginosis does not cause inflammation, and candida vaginitis causes a discharge that is thick and white.
15
Q
What is the most appropriate infertility treatment for a patient with premature ovarian failure who wants to get pregnant?
A
In vitro fertilization with donor oocytes
16
Q
Estrogen replacement therapy affects the metabolism of what other hormone?
A
Thyroid hormone
The requirement for L-thyroxine increases when estrogen replacement therapy is started. Pregnancy also increases thyroid hormone requirements and patients should be monitored every 4-6 weeks for dose adjustments.
17
Multinucleated giant cells on Tzanck smear are characteristic of what?
Herpes and Varicella
17
During which phase of the menstrual cycle is the cervical mucus profuse, clear, and thin, and will stretch to approximately 6cm and exhibit ferning on a microscope slide smear preparation?
The ovulatory phase
18
What is the standard of care for a threatened abortion?
Reassurance and outpatient follow up in 1 week for repeat ultrasonogram
*Bed rest and abstaining from sexual intercourse are usually recommended because this will prevent any feelings of guilt on the part of the parents in the case that pregnancy is actually lost, however, there is no evidence of the benefit of these interventions on the outcome.*
19
What is the next step in working up a patient with bilateral guaiac-negative nipple discharge?
Workup includes ruling out pregnancy, measuring serum prolactin and TSH levels, and possibly an MRI of the brain to rule out prolactinoma
*Prolactinoma, hypothyroidism, overstimulation of the nipple, oral contraceptice pills, and medications which lower dopamine levels are common causes of galactorrhea.*
20
What is the next step in management of a woman with HELLP syndrome at 34 weeks of gestation?
Induction of labor
*Prior to 34 weeks or lung maturity, steroids can be considered to promote lung maturity prior to delivery, contingent on the mother and fetus being stable.*
20
When should a pregnant woman be tested for group B strep colonization?
35-37 weeks
* Women who are colonized with GBS receive prophylactic antibiotics (penicillin or ampicillin) at the time of delivery.*
* Women who have had GBS bacteriuria during pregnancy or who have previously delivered a child that developed an early-onset GBS infection are automatically given prophylactic antibiotics regardless of the results of a rectovaginal culture.*
20
Women affected by polycystic ovarian syndrome (PCOS) are at increased risk of what cancer?
Endometrial hyperplasia and carcinoma
*Women with PCOS are oligo- or an-ovulatory and are deficient in progesterone secretion; thus, they usually have a constant and unbalanced mitogenic stimulation of the endometrium by estrogens leading to endometrial hyperplasia, intermittent breakthrough bleeding and dysfuntional uterine bleeding. This unopposed estrogen stimulation leaves them at increased risk for endometrial cancer.*
21
What can sometimes be seen in patients with systemic lupus erythematosus (SLE) and is a potential cause of recurrent pregnancy loss due to thrombus development within the placenta?
Lupus anticoagulant
21
Polycystic ovarian syndrome is a common cause of amenorrhea due to anovulation. What is another common cause of anovulatory amenorrhea?
Obesity
*FSH and LH levels are usually normal.*
21
What is the diagnosis for a newborn with a small body size, microcephaly, digital hypoplasia, nail hypoplasia, midfacial hypoplasia, hirsutism, cleft palate and rib anomalies?
Fetal hydantoin syndrome
Caused by maternal phenytoin or carbamazepine use during pregnancy
22
What is the treatment of choice for candida vulvovaginitis?
An azole antifungal such as oral fluconazole
*Topical Nystatin can also be used.*
22
Patients with what diagnosis present with primary amenorrhea, nondeveloped internal reproductive organs, a normal XX karyotype, normal female levels of testosterone, and normal axillary and pubic hair development?
Mullerian agenesis
23
45 XO is the genotype found in patients with what diagnosis?
Turner syndrome
*These patients have primary amenorrhea, but the FSH level is generally elevated due to primary ovarian failure.*
24
What two tests are used to screen for syphilis?
Nontreponemeal serologic tests: Venereal Disease Research Laboratory (VDRL) and Rapid Plasma Reagin (RPR)
25
What is the recommended management of a patient with an active genital herpetic lesion who is in active labor?
Immediate C-section
*Neonatal HSV is a severely morbid and potentially fatal illness*
26
Infants born to patients with Graves disease treated with surgery are at risk for what?
Thyrotoxicosis
*This would occur because of the passage thyroid stimulating immunoglobulin across the placenta. Thyroid stimulating immunoglobulin remains as high as 500 times the normal value for several months following thyroidectomy.*
26
What is the most common preventable cause of fetal growth restriction in the United States?
Cigarette smoking
*1 in 3 cases of FGR is attributable to smoking, and women who smoke while pregnant have a 3 to 4-fold increased risk of having a growth restricted infant.*
28
When do amniotic fluid embolisms usually occur?
During amniocentesis or during labor
28
What are the 3 hallmark features of endometriosis?
1. Dyspareunia
2. Dysmenorrhea
3. Dyschezia
*Other features include pelvic pain and infertility. Treatment options include combined oral contraceptives, GnRH analogs (IE Leuprolide), and danazol*
29
How does hyperprolactinemia cause amenorrhea?
Elevated prolactin levels suppress GnRH release thereby suppressing LH and FSH production and ovulation. This is the reason for anovulation and amenorrhea in lactating mothers
30
Why is Trimethoprim-Sulfamethoxazole contraindicated in the first and third trimesters?
1st Trimester: Interferes with folic acid metabolism
3rd Trimester: Increases risk of kernicterus (bilirubin-induced brain dysfunction) in the newborn
30
What is the treatment of choice for treating a deep vein thrombosis (DVT)?
Anticoagulation with heparin
31
Why are fluoroquinolones contraindicated during pregnancy?
They can potentially cause arthropathy in the unborn fetus
31
What is the gold standard for evaluation the cervix for cervical incompetence in pregnancy?
Transvaginal ultrasound
*A cervical length below the 10th percentile for gestational age is considered a short cervix. This includes cervices less than 25 mm at gestational age 23-28 weeks*
31
What test is necessary to confirm the diagnosis of missed abortion?
Transvaginal ultrasound
32
What is the most important intervention for preventing spread of HIV from mother to fetus?
Zidovudine to the mother throughout pregnancy and labor, as well as to the neonate for the first 6 weeks of life
33
Bleeding is seen in what percent of placental abruptions?
80%
33
What is the first step in management of a pregnant patient who presents with vaginal bleeding and hemodynamic instability?
Obtain venous access (with two large bore needles)
*Maintainance of airway, breathing, and circulation is always the first priority in any patient presenting for emergent care. C-section may later be needed if the patient continues to be unstable*.
33
All pregnant women should have an oral glucose tolerance test at what gestational age of pregnancy?
24 to 28 weeks gestation
*High-risk patients (markedly obese, family history of diabetes) can be screened earlier in pregnancy.*
34
What can be used to differentiate symmetric from asymmetric fetal growth restriction (FGR)?
Head to abdomen circumference ratio
35
What is the preferred form of hormonal contraception for lactating mothers?
Progestin-only oral contraceptives
37
What should be performed early in the evaluation of an infertile couple, usually as the initial screening test?
Semen Analysis
*Male factor accounts for 20-30% of infertility cases.*
38
What is indicated for a patient with polycystic ovarian syndrome (PCOS) and impaired glucose tolerance?
Metformin
*Metformin is indicated in PCOS patients with impaired glucose tolerance becuase it helps in preventing type 2 diabetes mellitus as well as improving obesity, hirsutism, menstrual irregularity, and infertility.*
39
Idiopathic central precocious puberty is managed with GnRH agonist therapy in order to prevent what?
Premature fusion of the epiphyseal plates
*This would otherwise lead to a short stature.*
40
Hypotension is a common side effect of epidural anesthesia. What is the mechanism of this effect?
Blood redistribution to the lower extremities and venous pooling
41
Hyperemesis gravidarum presents with severe and persistent vomiting, weight loss, and what?
Ketonuria
42
Does the use of combination oral contraceptive pills cause weight gain?
No
*Numerous recent studies have determined that weight gain is not associated with the use of combination oral contraceptives. Weight gain has been reported with medroxyprogesterone use but controlled studies have not been done to substantiate this effect.*
43
Post-term pregnancies are at an increased risk for what?
Oligohydramnios
*This is associated with increased fetal morbidity. Post-term pregnancies should be monitored for oligohydramnios twice weekly.*
44
Isotretinoin is associated with what congenital abnormalities?
1. Craniofacial dysmorphism
2. Heart defects
3. Deafness
44
Patients with what diagnosis present with amenorrhea, normally developed breasts, absent pubic and axillary hair, absent internal reproductive organs, and a 46 XY karyotype?
Androgen resistance
*In this condition, serum testosterone levels are in a range typical for males. The internal reproductive organs do not develop because the testes are still present and secrete mullerian inhibiting factor.*
44
What most commonly affects postmenopausal women and manifests with vulvar pruritus and discomfort? Exam shows porcelain-white atrophy.
Lichen sclerosus
*Biopsy should be considered to rule out vulvar squamous cell carcinoma.*
44
What is considered first-line therapy for lichen sclerosus?
High-potency topical steroids
46
How long after infection with Treponema pallidum before the patient develops a painless papule at the site of inoculation?
2-3 weeks after infection
*If left untreated, the chancre of primary syphilis heals spontaneously within one to three months.*
47
Human chorionic gonadotropin (hCG) is secreted by what?
Syncytiotrophoblast
49
What is a common cause of recurrent mid trimester abortions?
Cervical incompetence
51
1. What stimulates prolactin secretion?
2. What inhibits prolactin secretion?
1. Serotonin and TRH stimulate prolactin
2. Dopamine inhibits prolactin
*Hypothyroidism results in elevated TSH and TRH levels and can subsequently cause hyperprolactinemia*.
52
What is caused by increased levels of prostaglandins and presents with lower abdominal pain that occurs with mestruation?
Primary dysmenorrhea
*NSAIDS and oral contraceptive pills can be used to improve symptoms.*
54
What is the treatment for vaginismus?
Relaxation, Kegel exercises (to relax vaginal muscles), and insertion of objects of gradually increasing size to encourage desensitization
54
What is the treatment of choice for a patient with pelvic inflammatory disease (PID) who cannot take oral medication because of nausea and vomiting?
Hospitalization and Inpatient treatment with cefotetan and doxycycline
*IV Clindamycin/gentamicin can also be given*
56
What happens to Inhibin levels in a patient with Turner syndrome?
Inhibin is decreased
*Inhibin is a marker of ovarian function which is reduced in Turner syndrome.*
56
What is characterized by a patient with a male genotype, female external genitalia, and virilization typically occurring at puberty?
5-alpha-reductase deficiency
57
What occurs most frequently in women above age 40 and typically presents with secondary dysmenorrhea and menorrhagia? Physical examination will reveal an enlarged and generally symmetrical uterus.
Adenomyosis
58
Painful genital ulcers with a deep, purulent base and painful lymphadenopathy are characteristic of what diagnosis?
Chancroid caused by infection with haemophilus ducreyi
*This is differentiated from herpes genitalis which presents with multiple vesicles following a prodrome of burning and pruritus.*
58
What is the next step in management of a patient with uniductal and guaiac positive nipple discharge?
Cytologic examination
*This allows the pathologist to examine cells from the duct to distinguish carcinoma, proliferative changes, and inflammatory processes. Cytology is not indicated for guaiac negative discharge.*
59
What is the best test for detection of fetal chromosomal abnormalities in the first trimester of pregnancy?
Chorionic villus sampling
*It can be done between 10 and 12 weeks of gestations thus offering the advantage of an early diagnosis. Amniocentesis is done between the 16th and 18th week of gestation.*
60
What are 5 signs of chorioamnionitis?
1. Maternal fever
2. Leukocytosis
3. Uterine tenderness
4. Maternal tachycardia
5. Fetal tachycardia
60
How does one screen for gestational diabetes?
One hour 50 gram oral glucose tolerance test between 24 and 28 weeks gestation
*After 1 hour, if glucose value is 140 mg/dL, a 3 hour oral glucose tolerance test is administered to confirm the diagnosis of gestational diabetes.*
61
In a pregnant patient, symmetrical pitting edema of both calves with no calf tenderness and in the absence of any other signs/symptoms/abnormalities is most likely due to what?
Benign edema of pregnancy
*Preeclampsia and DVT should also be considered, but are unlikely in the absence of other classic symptoms of these conditions.*
61
External cephalic version can be attempted in women with breech pregnancies at what Gestational age?
Greater than 37 weeks
*If there are no contraindications to vaginal delivery and fetal well-being has been established.*
63
Why are initial menstrual cycles in pubertal females usually irregular and often anovulatory?
Immaturity of the developing hypothalamic-pituitary-gonadal axis
## Footnote
*Inadequate production of of LH, FSH and other hormones required to induce ovulation.*
64
What is the earliest sign of magnesium sulfate toxicity?
Depression of the deep tendon reflexes
66
What test is used to confirm the diagnosis of syphilis?
1. Treponemal serologic test: Fluorescent treponemal antibody Absorption test (FTA-ABS)
2. Darkfield Microscopy
67
Why do obese women have milder menopause symptoms?
Increased peripheral conversion of androgens to estrogen
*The major source of estrogen in menopausal women is from the peripheral conversion of adrenal androgens by the aromatase enzyme present in adipose tissue. This process is increased in obese women.*
68
Multiple painful vesicles in the genital region following a prodrome of burning and pruritus is characteristic of what diagnosis?
Herpes genitalis
*This is differentiated from chancroid which presents as deep, painful ulcers with a purulent base and painful lymphadenopathy.*
69
What is the most likely cause of infertility in a patient with polycystic ovarian syndrome (PCOS)?
Anovulation
70
What is the _most common_ risk factor for placental abruption?
Maternal hypertension
72
What is the treatment for intrahepatic cholestasis of pregnancy?
Ursodeoxycholic acid: increases bile flow and can relieve pruritus
*Hydroxyzine and cholestyramine are alternative therapies, though they are less effective and can have concerning side effects.*
73
A finding of atypical squamous cells of undetermined significance on cytology in a patient aged 25 years or greater is managed how?
Human Papillomavirus (HPV) DNA test
*Those who test positive for HPV require colposcopy. Patients with a negative HPV test can be followed with repeat pap smear and HPV test in 3 years.*
74
What is the treatment for moderate or severe atrophic vaginitis?
Local estrogen therapy
74
FSH elevation in the setting of _\>_3 months of amenorrhea in a woman under age 40 confirms what diagnosis?
Premature ovarian failure
75
What is the next step in management if maternal serum alpha-fetoprotein (MSAFP) levels are abnormal in a pregnant patient?
Ultrasonography
*This is done to confirm gestational age, detect fetal structural anomalies, detect multiple gestation, and confirm a viable pregnancy.*
77
What is the treatment of choice for bacterial vaginosis in a pregnant woman?
Oral metronidazole
*Oral metronidazole is the treatment of choice for bacterial vaginosis regardless of pregnancy status.*
78
The Center for Disease Control recommends that all pregnant women without contraindications be vaccinated against what?
Influenza
80
Aortic coarctation presents with elevated blood pressure in the upper extremities but low blood pressure in the lower extremities and is a common finding in what syndrome?
Turner syndrome
*Patients with Turner syndrome have ovarian dysgenesis and poor ovarian function.*
81
Bilateral breast tenderness and swelling that presents 24-72 hours post partum and peaks 3-5 days after delivery before resolving spontaneously is most likely due to what?
Breast engorgement
*This is a common problem associated with breast feeding.*
82
What complication of intrauterine fetal demise should be suspected when serum fibrinogen levels are borderline or low?
Disseminated intravascular coagulation
*Induction of labor is the most appropriate next step in management.*
83
What is the next step in working up a patient with primary amenorrhea who is shown to have a uterus on ultrasound?
Measure serum FSH
1. *If increased: Proceed to karyotyping*
2. *If decreased: Proceed to cranial MRI*
84
Why is erythromycin not used to treat Syphillis (treponema pallidum) in a pregnant patient?
Erythromycin is effective against T. Pallidum but it cannot cross the placenta and is therefore ineffective in treating pregnant patients
*Penicillin is considered to be the treatment of choice for pregnant patients with syphilis. If a patient is allergic to penicillin, the allergy should be confirmed with skin testing and the patient should then undergo desensitization so that she can safely take the medication.*
85
What is the first-line therapy for the majority of patients with premenstrual syndrome (PMS)?
Selective serotonin reuptake inhibitors
*Premenstrual dysphoric disorder (PMDD) is a severe variant of PMS, with prominent irritability and anger.*
87
What is the gold standard for diagnosing endometriosis?
Laparoscopy
89
What is the most commonly identified risk factor for placental abruption?
Hypertension
*Other risk factors include:*
1. *Prior placental abruption*
2. *Cocaine*
3. *Alcohol*
4. *Tobacco*
5. *Vascular diseases such as diabetes and SLE*
91
What causes thrombocytopenia and hemolytic anemia in a pregnant patient with normal PT and PTT, but also usually causes renal failure and is not necessarily associated with preeclampsia?
Hemolytic uremic syndrome (HUS)
*This is differentiated from HELLP syndrome which does not cause renal failure and is associated with preeclampsia.*
93
Up to what percent of females being evaluated for infertility are found to have endometriosis?
30%
*Patients with endometriosis are at an increased risk of decreased fertility or infertility.*
95
Maternal factors such as hypertension, smoking, hypoxia, vascular disease, and preeclampsia are typical causes of what kind of intrauterine growth restriction (IUGR)?
Asymmetric IUGR
*Asymmetric IUGR is a result of a late exposure to a maternal factor that does not allow optimal fetal growth. It is characterized by a normal or almost normal head size and a reduced abdominal circumference.*
95
A patient in the last 4-8 weeks of pregnancy who presents with irregular contractions felt in the lower abdomen that do not occur at shortening intervals or with increasing intensity is most likely experiencing what?
False labor
*In false labor, progressive cervical changes are absent, contractions are irregular and discomfort is readily relieved by sedation. All such patients need reassurance.*
97
Why is magnesium sulfate given to an eclamptic patient?
Prevent further development of seizures while delivery of the fetus is accomplished
*Eclamptic seizures are of very short duration (few seconds) so magnesium sulfate infusions are mainly to prevent the further development of seizures rather than controlling current seizures.*
98
What is a chronic condition associated with pelvic pain worsened by bladder filling or intercourse accompanied by urinary frequency, urgency and nocturia?
Interstitial cystitis (Painful bladder syndrome)
99
Failure to lactate in Sheehan's syndrome is due to what hormonal change?
Prolactin deficiency
*Hormones secreted from the anterior pituitary include prolactin, thyroid stimulating hormone (TSH), and follicle stimulating hormone (FSH).*
100
What is a normal biophysical (BPP) profile score?
8-10
*Repeat BPP once or twice weekly until term for high risk pregnancies.*
101
After pregnancy has been excluded, what 3 lab levels should be checked during initial workup of amenorrhea?
1. FSH to rule out ovarian failure
2. Prolactin to evaluate for hyperprolactinemia
3. TSH to evaluate for hypothyroidism
102
In postmenopausal women, the initial workup of an adnexal mass should include what 2 components?
1. Transvaginal ultrasound
2. Serum cancer antigen (CA-125) level
104
Why is Doxycycline and other tetracyclines contraindicated in pregnancy?
They interfere with bone and tooth development
## Footnote
*Children exposed to tetracycline in utero often have gray teeth. They should not be used in the second half of pregnancy or in children*
105
What is the management of choice for a patient with severe dysfunctional uterine bleeding (DUB) or a patient with moderate DUB but with active bleeding?
Estrogen
*High dose estrogen for uncontrolled bleeding.*
106
Jaundice in the third trimester with marked pruritis and elevated serum total bile acid concentrations are suggestive of what?
Intrahepatic cholestasis of pregnancy
*Pruritus is especially significant on the palms and soles and worsens at night.*
107
What test should be carried out if fetal movement decreases or becomes imperceptible by the mother?
A non-stress test (NST) to document fetal well-being
*In the presence of decreased fetal movements, fetal compromise should be suspected, and the best next step in management is a non-stress test. NST is usually performed in high-risk prenancies starting at 32-34 weeks gestation or when there is a loss of perception of fetal movements in any pregnancy.*
108
What is the appropriate next step in managing a patient that is less than 37 weeks pregnant with a fetus in breech presentation?
Routine follow-up
*Breech presentations often convert to vertex before the 37th week.*
109
What is human chorionic gonadotropin (hCG) mainly responsible for?
The preservation of the corpus luteum in early pregnancy
111
Why is the incidence of carpal tunnel syndrome increased during pregnancy?
Estrogen-mediated depolymerization of ground substance causes interstitial edema in the hands (and face) and thus increases pressure within the carpal tunnel
113
Postpartum endometritis is most commonly caused by what bacteria?
Polymicrobial infection
*Composed of gram positive and gram negative organisms, aerobic and anaerobic organsims and occasionaly other organisms.*
114
What 2 treatments can induce ovulation in a patient with polycystic ovarian syndrome (PCOS)?
1. Clomiphene citrate
2. Metformin
115
What is the treatment for magnesium sulfate toxicity?
Administration of calcium gluconate
*Also, magnesium sulfate administration must be stopped.*
117
What otherwise abnormal findings are normal in the immediate postpartum period?
1. Low-grade fever
2. Leukocytosis
3. Vaginal discharge (initially bloody, then serous, and finally white to yellow in color days following delivery)
118
Painless genital ulcers with a red and beefy base, and no associated lymphadenopathy, that do not resolve without antibiotic treatment are characteristic of what diagnosis?
Granuloma inguinale (Donovanosis) caused by Klebsiella granulomatis
This differs from primary syphilis which will resolve without antibiotics
119
Abdominal pain in a young female in the middle of her cycle with a benign history and clinical examination is most likely what?
Mittelschmerz (midcycle pain)
*This is common in women with regular menstrual periods who are not taking birth control pills (women who are ovulating).*
120
How is the management of hypothyroidism affected by pregnancy?
Levothyroxine dose must be increased
*This increased levothyroxine requirement occurs mostly during the first trimester.*
121
What effect does primary ovarian failure have on FSH, LH, and the FSH/LH ratio?
1. FSH: Increased
2. LH: Increased
3. FSH/LH: \>1
*The elevation of FSH is generally greater than that of LH becuase of the slower clearance of FSH from the circulation.*
123
Bilateral solid ovarian masses discovered incidentally in a multiparous African-American pregnant woman most likely signify what
A pregnancy luteoma
*This is a benign self-limited condition and requires no treatment.*
125
In pregnant patients, asymptomatic bacteriuria is treated with what?
7-day course of nitrofurantoin, amoxicillin, or a first-generation cephalosporin
*Shorter courses (3 days for example) are ineffective at eradicating asymptomatic bacteriuria of pregnancy.*
126
What is indicated in cases of dysfunctional uterine bleeding (DUB) in women \>35 years old?
Endometrial biopsy
*This is also indicated in cases of DUB if hypertension, diabetes, or obesity are present.*
127
What is the first step in management of a patient suspected of having an amniotic fluid embolism presenting as abrupt onset hypoxia with respiratory failure, cardiogenic shock, and DIC?
Intubation and mechanical ventillation
*Respiratory support is always the first step in management.*
129
What asymptomatic heart condition frequently becomes symptomatic in pregnancy?
Mitral stenosis (typically due to rheumatic heart disease)
*Affected women often become symptomatic during pregnancy because of the physiologically increased total blood volume.*
131
What is the most likely cause of right upper quadrant pain in a pregnant patient with severe preeclampsia?
Distention of the liver (Glisson's) capsule
*Centrilobular necrosis, hematoma formation and the formation of thrombi in the portal capillary system can all cause swelling of the liver with destention of the Glisson's capsule. This results in right upper quadrant pain as the peritoneum is innervated by somatic nerves that provide localized sensation of pain.*
132
A biophysical profile score of 2 or less is consistent with what?
Severe fetal asphyxia
*For any biophysical profile score of 4 or less, delivery is indicated if the fetus is greater than 26 weeks gestational age.*
134
What is the most appropriate next step in management of a pregnant patient at 32 weeks gestation who has mild preeclampsia?
Bed rest at home with frequent follow-up
135
The combination of thrombocytopenia, microangiopathic hemolytic anemia, and increased liver enzymes in a patient with preeclampsia is defined as what?
HELLP syndrome
137
Tzanck smear is a dermatologic test in which scrapings are taken from the base of an ulcer and is used in the diagnosis of what 3 infections?
1. Herpes simplex
2. Varicella
3. Cytomegalovirus
*Multinucleated giant cells on Tzanck smear are characteristic of Herpes and Varicella*.
137
The combination of primary amenorrhea, bilateral inguinal masses, and breast development without pubic or axillary hair is strongly suggestive of what diagnosis?
Androgen insensitivity syndrome
*A blind vaginal pouch and a karyotype of 46 XY are other clues.*
138
Steroid treatment is effective at accelerating lung maturity and should be used at what stage of pregnancy?
Between 24 and 34 weeks
139
Pregnant women with asymptomatic bacteriuria should be treated with antibiotics. Which antibiotics are most appropriate?
First line antibiotics for asymptomatic bacteriuria during pregnancy include:
1. Amoxicillin
2. Nitrofurantoin
3. Cephalexin
140
At the first prenatal visit, what should be performed?
Blood typing and Rh antibody testing (in Rh (D) negative women)
142
Systemic corticosteroids are administered for preterm labor at what gestational age range?
24-34 weeks
*Tocolysis should then be attempted with the goal being to maintain the pregnancy for at least 48 hours in order to realize the maximum benefit from the steroids.*
143
What is the most significant risk factor for distal limb reduction defects associated with chorionic villus sampling (CVS)?
Gestational age of the fetus
*CVS before 10 weeks gestational age is associated with greater risk.*
145
What is the most common cause of decreased fertility in women in their fourth decade who are still experiencing menstrual cycles is what?
Age-related decreased ovarian reserve
146
Gestational diabetes is most commonly treated with what?
First a low sugar diet, but if diet fails to produce euglycemia, insulin is the treatment of choice
148
Secondary amenorrhea is relatively common in elite female athletes and results from what?
Estrogen deficiency
*Amenorrhea is thought to occur in female athletes when there is a relative caloric deficiency secondary to inadequate nutritional intake as compared to the amount of energy expended.*
149
In what phase of the menstrual cycle is the cervical mucus thick, scant, and acidic, and will not allow penetration by spermatozoa?
The early follicular phase immediately following menstruation
150
What must be avoided by any patient being treated for bacterial vaginosis or trichomonal vaginitis?
Alcohol
*Patients who take metronidazole should abstain from drinking alcohol, as it is associated with a disulfiram-like reaction.*
151
What is the most appropriate treatment of chorioamnionitis associated with premature rupture of membranes?
Systemic broad-spectrum antibiotic therapy and expedited delivery of the fetus
152
What presents similarly to mastitis but with a palpable, fluctuant mass?
Breast abscess
*Treatment is drainage and antibiotics*
153
Maternal obstetrical trauma, past gynecological procedures (LEEP or cone bipsy), DES exposure, multiple gestation, and prior history of a preterm birth or a second trimester pregnancy loss are all risk factors for what?
Maternal cervical insufficiency
153
What is the most common cause of abnormal uterine bleeding?
Dysfunctional Uterine Bleeding (DUB)
*This refers to heavy vaginal bleeding that occurs in the absence of structural or organic disease. It is most often the result of anovulation.*
154
What two diagnoses are possible in a pregnant patient with increased blood pressure prior to 20-weeks gestation?
1. Chronic hypertension
2. Hydatidiform mole
155
What are the most appropriate first steps in the management of variable decelerations?
Oxygen administration and change in maternal position
156
What is the most common cause of an abnormal maternal serum alpha-fetoprotein (MSAFP) level?
Gestational age error
158
Sudden onset of abdominal pain, fetal heart rate abnormalities, and recession of the presenting part during active labor indicate what probable diagnosis?
Uterine rupture
## Footnote
*Risk factors include a pre-existing uterine scar or abdominal trauma.*
160
What is the most common cause of mucopurulent cervicitis?
Chlamydia trachomatis
161
Diabetic neuropathy causes what kind of incontinence?
Overflow incontinence
162
What is the USPSTF recommendation on screening for Chlamydia and Gonorrhea in pregnant women?
Only screen women age 24 and younger, and those at increased risk
*Increased risk includes a history of sexually transmitted infections, and new or multiple partners.*
163
What is the most appropriate test to confirm the diagnosis of intrauterine fetal demise (IUFD)?
Real-time ultrasonography
*To demonstrate an absence of fetal movement and cardiac activity*.
164
Small genital warts (lesions) can be treated with what?
Trichloracetic acid or podophyllin
165
The presence of dysmenorrhea, heavy menses, and an enlarged uterus is classic for what?
Uterine fibroids
166
The risk of fetal polycythemia is increased in what gestational disorder?
Gestational diabetes
*Polycythemia in an infant of a diabetic mother is the result of fetal hypoxia that occurs in the face of the increased basal metabolic rate induced by hyperglycemia. Increased erythropoietin production by the fetus increases the red blood cell mass and oxygen carrying capacity of the blood.*
167
What should be ruled out in pregnant patients with severe vomiting?
Gestational trophoblastic disease
*Measurement of quantitative beta-hCG should be checked first. If the beta-hCG is markedly elevated, an ultrasonogram is then performed.*
168
What is the test of choice for diagnosis of ectopic pregnancy at beta-hCG levels of 1,500-6,500 IU/L?
Transvaginal ultrasound
*Transvaginal ultrasound can demonstrate an intrauterine gestational sac when the beta-hCG is as low as 1500 IU/L (sometimes even at 800 IU/L). If transvaginal ultrasound reveals an intrauterine sac in the setting of a positive beta-hCG, then ectopic pregnancy is virtually ruled out. If transvaginal ultrasound reveals an adnexal sac and no intrauterine sac in this setting, then ectopic pregnancy is confirmed.*
169
What is on the differential diagnosis of a patient who is 46 XY but has a female phenotype?
1. Androgen insensitivity
2. 5-alpha-reductase deficiency
170
It is recommended that, regardless of risk factors, all pregnant women be screened for what?
Syphilis
*Screening should be performed at the first prenatal visit and is typically accomplished via the rapid plasma reagin (RPR) or venereal disease research laboratory (VDRL) test. When the screening test is positive, the diagnosis can be confirmed with the fluorescent treponemal antibody absorption (FTA-ABS) test.*
171
What is the most important complication of preterm premature rupture of membranes (PPROM)?
Pulmonary hypoplasia (immaturity)
172
What happens to serum BUN and creatinine during pregnancy?
They are usually decreased
*This is due to an increase in renal plasma flow and glomerular filtration rate.*
173
What is the treatment of choice for premenopausal women with simple or complex endometrial hyperplasia _without atypia_?
Cyclic progestins
*All patients should undergo repeat biopsy after 3-6 months of treatment. The risk of progression to endometrial cancer in patients with simple or complex hyperplasia without atypia is low (1% and 3% respectively).*
174
In cases of aneuploidy, the maternal quadruple screen will return with what results?
1. Beta-hCG: Increased
2. MSAFP: Decreased
3. Estriol: Decreased
4. Inhibin A: Increased
175
Painful 3rd trimester bleeding with normal ultrasound is most likely due to what?
Placental abruption
*The role of ultrasound in the evaluation of antepartum hemorrhage is primarily to rule out placenta previa and not to diagnose placental abruption.*
176
This is a rare psychiatric condition in which a woman presents with nearly all signs and symptoms of pregnancy (amenorrhea, enlargement of the breasts and abdomen, morning sickness, weight gain, sensation of fetal movement, and positive urine pregnancy test per patient); however, ultrasound reveals a normal enometrial stripe and negative pregnancy test.
Pseudocyesis
*Pseudocyesis is usually seen in women who have a strong desire to become pregnant. This is a form of conversion disorder, and management requires psychiatric evaluation and treatment.*
177
When is internal podalic version indicated?
During twin delivery to convert the second twin from a transverse or oblique presentation to a breech presentation for subsequent delivery
178
What are the first-line agents for management of essential hypertension during pregnancy?
Labetalol and Methyldopa
179
What is the most effective parameter for estimation of fetal weight in cases of suspected fetal growth restriction (FGR)?
Abdominal circumference
180
1. In which tissues is Raloxifene an estrogen receptor agonist?
2. In which tissues is Raloxifene an estrogen receptor antagonist?
1. Agonist in bone tissue
2. Antagonist in breast and vaginal tissue
*These characteristics make it a first-line agent for the prevention of osteoporosis, and it decreases breast cancer risk. It does, however, increase the risk of thromboembolism.*
181
What are the 2 most appropriate agents to treat hypertensive emergencies in pregnancy?
Intravenous hydralazine and labetalol
## Footnote
*Methyldopa has a long history of safety in pregnancy but is not used to treat hypertensive emergencies due to its slow onset and sedative side effect at high doses.*
