Obstetrics and Gynecology

Question 1

Questions 1 and 2 pertain to the following case.
A 36-year-old woman is in the clinic for her 2-week postpartum checkup, wanting to know which contraceptive
method she should use. She had to stop breastfeeding when
she was 5 days postpartum, after she had a stroke. Her
medical history is significant for morbid obesity, a tilted
and bicornate uterus, allergic rhinitis, and a cerebrovascular accident (5 days postpartum). She is allergic to latex.
Current medications are lisinopril 5 mg/day, hydrochlorothiazide 12.5 mg/day, simvastatin 20 mg every night, and
aspirin 81 mg/day (all medications initiated 1.5 weeks ago).
1. Which is the best contraceptive recommendation for
this woman?
A. Depot medroxyprogesterone acetate.
B. Levonorgestrel intrauterine device (LNG-IUD).
C. Contraceptive sponge.
D. Male polyurethane condom.
2. The patient calls to ask for another contraceptive
choice because she cannot afford the item you recommended. She states that the free clinic does not carry
the item either. Of the alternative contraceptives that
can be provided free from either your clinic or the free
clinic, which is the best recommendation?
A. Female condom.
B. Male latex condom.
C. Yaz (ethinyl estradiol and drospirenone).
D. Ella (ulipristal)

Answer 1

1. Answer: D
   Depot medroxyprogesterone acetate (Answer A) causes
   considerable weight gain, making it a less-than-optimal
   choice for this patient. Cerebrovascular accident is also
   a relative contraindication (medical eligibility criteria
   category 3) for progestin-only contraceptives of depot
   medroxyprogesterone and continuation of POPs and
   implants. The levonorgestrel IUD (Answer B) should not
   be used because the patient has structural abnormalities of
   the uterus. The contraceptive sponge (Answer C) should
   be avoided because of the patient’s uterine structural
   abnormalities and because she is recently postpartum.
   The polyurethane condom (Answer D) is the best option
   because the patient has no contraindications or allergies
   that would prohibit its use.
2. Answer: A
   The patient has no contraindications or allergies to the
   female condom (Answer A). However, she has a latex
   allergy, so the male latex condom (Answer B) would not
   be a good choice. Estrogen-containing contraceptives
   (Answer C) are contraindicated (medical eligibility criteria
   category 4) for patients with stroke, according to the CDC
   and the World Health Organization. Ulipristal (Answer D)
   is a form of EC; it should not be used as a regular form of
   contraception

Question 2

3. A double-blind randomized trial is under way to
   evaluate the effects of depot medroxyprogesterone,
   leuprolide, and placebo on the bone mineral density of
   600 patients with endometriosis. Which statistical test
   is most appropriate?
   A. Student t test.
   B. Fisher exact test.
   C. Kruskal-Wallis test.
   D. Analysis of variance

Answer 2

3. Answer: D
   Analysis of variance (Answer D) would be most appropriate because the trial consists of more than two groups and
   involves continuous data that are most likely normally distributed (n=600). Although the Student t test (Answer A)
   is for continuous data, it should be used only if two groups
   are being compared. Both the Fisher exact test (Answer B)
   and the Kruskal-Wallis test (Answer C) are for nonparametric data

Question 3

4. A 40-year-old woman asks to see the pharmacist after
   her physician’s appointment. She states that she was
   prescribed a new drug during her pregnancy. She is
   uncomfortable taking medications during her pregnancy because her family said that they all carry risk.
   Which is the best information to include when educating the patient on the risks and benefits of the drug?
   A. Rate of birth defects in studies of animals.
   B. Gestational timing of risks and pregnancy.
   C. Molecular weight of the drug.
   D. Half-life of the medication

Answer 3

4. Answer: B
   Although molecular weight is important in determining
   whether a drug will cross the placenta, the risk of malformations is not directly addressed (Answer C is incorrect).
   Information from studies of animals helps determine the
   potential risks of drugs in humans but does not confer
   exact risks in humans (Answer A is incorrect). Educating
   the patient on the gestational timing of risks and on the
   current stage of pregnancy is imperative to understanding whether the patient has any chance of experiencing
   that birth defect (Answer B is correct). The half-life of a
   medication does not affect the risk of medication exposure
   during pregnancy (Answer D is incorrect).

Question 4

5. A 32-year-old woman who is 4 weeks postpartum calls
   your office asking whether it is okay for her to start
   terbinafine therapy for 6 months for toe onychomycosis that began during the pregnancy. She states that she
   consulted a podiatrist yesterday and that the podiatrist
   gave her this prescription. She reports no pain, redness, or difficulty walking but states she does not like
   how her toes look when wearing sandals. She is currently breastfeeding every 2 hours. You will find the
   following information regarding use in breastfeeding
   in the reference Medications & Mothers’ Milk (Hale
   2019): milk/plasma ratio unknown; relative infant
   dose unknown; half-life 26 hours; 99% protein bound;
   and molecular weight 291 Da. Which is the best
   recommendation?
   A. Delay treatment until finished with breastfeeding.
   B. Change to itraconazole.
   C. Use topical terbinafine.
   D. Schedule doses right after feedings

Answer 4

5. Answer: A
   The best recommendation is to delay the treatment until
   after she stops breastfeeding (Answer A is correct). The
   drug is likely to cross into breast milk, but exact concentrations are unknown. Because of its long half-life and therapy
   duration, the infant would be exposed to the drug. The
   patient, who is currently asymptomatic, is seeking treatment only for cosmetic reasons. Itraconazole is an option
   for treating onychomycosis; however, it has decreased efficacy compared with terbinafine (Answer B is incorrect).
   Topical terbinafine is not effective for treating onychomycosis (Answer C is incorrect). Scheduling the doses right
   after feedings is recommended to minimize infant exposure; however, because the half-life is long and the baby is
   feeding every 2 hours, this recommendation is unlikely to
   decrease infant exposure (Answer D is incorrect)

Question 5

6. A 21-year-old woman is in the office for a follow-up of
   her dysmenorrhea. She states that because ibuprofen
   has only slightly improved her pain, she would like
   something else. She is currently in a monogamous
   relationship and would like contraceptive protection
   as well. Her vital signs today include the following:
   height 63 inches, weight 99 kg (220 lb), blood pressure 118/68 mm Hg, and heart rate 72 beats/minute.
   Which is the best recommendation?
   A. Ethinyl estradiol and norelgestromin (Xulane):
   Apply one patch every week for 3 weeks; then
   repeat after a 1-week hormone-free interval.
   B. Ethinyl estradiol and norelgestromin (Xulane):
   Apply one patch every week for 11 weeks; then
   repeat after a 1-week hormone-free interval.
   C. Ethinyl estradiol 35 mcg and ethynodiol diacetate
   1 mg (Kelnor 1/35): Take one tablet every day for
   3 weeks; then repeat after a 7-day hormone-free
   interval.
   D. Ethinyl estradiol 35 mcg and ethynodiol diacetate
   1 mg (Kelnor 1/35): Take one tablet every day for
   11 weeks; then repeat after a 7-day hormone-free
   interval

Answer 5

6. Answer: D
   Because the patient has a BMI >30, Xulane is not recommended because of decreased efficacy and increased
   thromboembolic risk, making Answer A and Answer B
   incorrect. Estrogen-progestin contraceptives (Answer C
   and Answer D) are second-line agents after NSAIDs for
   treating dysmenorrhea because they can decrease menstrual length and volume. Extended-interval dosing is
   preferred because it decreases the frequency of menses,
   making Answer D correct

Question 6

7. A 49-year-old woman is initiating therapy with
   estradiol valerate and dienogest (Natazia) for perimenopausal symptoms and contraceptive needs. You
   are asked to educate her about this product. Which
   option provides the best information for the patient
   regarding the minimal time a backup method of contraception should be used after initiation?
   A. 48 hours.
   B. 7 days.
   C. 9 days.
   D. 28 days.

Answer 6

7. Answer: C
   Natazia is a quadriphasic hormonal contraceptive that
   requires 9 days of backup contraception. The first two pills
   contain only estrogen, and ovulation protection does not
   occur until after the seventh dose. The egg is only viable
   for up to 48 hours after ovulation, so 9 days (Answer C) are
   required to provide pregnancy protection

Question 7

8. A 38-year-old woman is calling because of the intolerable vasomotor symptoms she is experiencing, which
   interfere with her daily activities. Her medical history includes breast cancer (diagnosed 3 months ago).
   She takes trastuzumab. She notes that the physician
   told her that her treatment caused menopause. She
   states her hot flashes occur at least 12 times a day
   and cause her to change clothes often. She would like
   additional therapy. Blood pressure is 104/64 mm Hg,
   and heart rate is 66 beats/minute. Which is the best
   recommendation?
   A. Conjugated equine estrogens.
   B. Venlafaxine.
   C. Clonidine.
   D. Black cohosh

Answer 7

8. Answer: B
   Estrogens should be avoided because of the patient’s
   active breast cancer (Answer A is incorrect). Venlafaxine
   has shown efficacy in decreasing vasomotor symptoms in
   patients with and without breast cancer (Answer B is correct). Clonidine improves vasomotor symptoms but may
   not be the best choice because this patient’s blood pressure
   Obstetrics and Gynecology
   ACCP/ASHP 2023 Ambulatory Care Pharmacy Preparatory Review and Recertification Course
   505
   is low (Answer C is incorrect). Black cohosh has not been
   effective in reducing vasomotor symptoms in patients with
   breast cancer (Answer D is incorrect).

Question 8

9. A 25-year-old woman was recently given a diagnosis
   of endometriosis. She is having trouble coping with
   the diagnosis and wants to find a support group. Which
   is the best resource for finding local support groups?
   A. Association of Reproductive Health Professionals.
   B. American College of Obstetricians and
   Gynecologists (ACOG).
   C. Endometriosis Association.
   D. National Women’s Health Network

Answer 8

9. Answer: C
   The Endometriosis Association (Answer C) provides
   contact information for local support groups and patient
   information. The Association of Reproductive Health
   Professionals (Answer A), ACOG (Answer B), and the
   National Women’s Health Network (Answer D) provide
   patient information and health care–related information