Review Flashcards

Question

Septic abortion

Answer 1

Fever and infection signs plus abortion. empiric broad-spectrum IV antibiotics such as clindamycin and gentamicin; IV fluid resuscitation; and suction and curettage

Answer 2

Separation of placenta before birth. vaginal bleeding, abdominal pain, back pain. > 34 weeks, hemodynamically stable > deliver.

Answer 3

34 - 36+6 weeks. 2 doses, 24 hours apart.

Answer 4

Stop contractions: beta-mimetics (e.g., terbutaline, ritodrine, isoxsuprine), cyclooxygenase inhibitors (e.g., indomethacin, sulindac), magnesium sulfate, calcium channel blockers (e.g., nifedipine), oxytocin antagonists (e.g., atosiban), and nitric oxide donors (e.g., glyceryl trinitrate).

Answer 5

Contains the fallopian tubes, ovaries, ovarian and uterine vessels, and the uterine ligaments (e.g., suspensory ligament of the ovary)

Answer 6

Contains the uterine artery, ligated during hysterectomies.

Answer 7

soft, boggy uterus, bleedig.

Answer 8

Intrapartum antibiotics without further culture. Cefazolin If penicillin allergy > clindamycin or vancomycin.

Answer 9

Hyperinsulinemia > Theca cells > increased androgen production > increased LH secretion Elevated LH:FSH ratio disrupts follicle maturation. prevents progesterone/CL maturation > excessive estrogen proliferative phase WITHOUT progesterone secretory phase. Primary amenorrhea or irregular/heavy bleeding (thick endometrium). Risk of Type I endometrial cancer

Answer 10

Head compression Line up with contractions

Answer 11

Cord Compression Do not line up with contractions

Answer 12

Placental insufficiency AFTER the contraction Decrease > 15, for 30 seconds

Answer 13

Low FSH and LH Stress, exercise Pulsatile GnRH treatment

Answer 14

Antiphospholipid antibody syndrome - strongly associated with systemic lupus erythematosus. Features consistent with antiphospholipid antibody syndrome (e.g., multiple first-trimester pregnancy loss) > Testing for anticardiolipin antibody

Answer 15

Diagnose autoimmune hemolytic anemia. Normocytic anemia, hyperbilirubinemia.

Answer 16

Hemoglobin electrophoresis Microcytic anemia (extreme)

Answer 17

Staph Aureus Remove foreign body, abx (vancomycin and clindamycin, fluid replacement).

Answer 18

Uterine prolapse Mechanical support

Answer 19

joint pain, thrombocytopenia, increased PTT, elevated creatinine. In APS > form procoagulants > placental thrombosis > miscarriage.

Answer 20

oral glucose challenge test

Answer 21

Elevated HCG in pregnancy > lutein cells > tumors Virilization, deep voice, clitoromegaly US: unilateral/bilateral solid mass on ovary, > 4cm, arterial/venous flow. Many regress spontaneously postpartum, otherwise surgery to remove.

Answer 22

Most accurate gestational age in the first trimester. After 14 weeks > biparietal diameter, femoral length, head/abdominal circumference.

Answer 23

Bone/teeth issues

Answer 24

Breast ultrasound is the most appropriate next step when evaluating a palpable breast mass in women < 30 years of age. Premenopausal women < 30 years of age often have dense breast tissue, which decreases the diagnostic accuracy of mammography.

Answer 25

urinary incontinence/post void dripping, dysuria, dyspareunia

Answer 26

fetal demise, placental hematoma > DIC. Systemic activation of clotting cascade > microthrombi > exhausts clots > elevated prothrombin time. Systemic consumption of pro and anticoagulants > abnormal bleeding. Additional laboratory findings that may be seen in DIC include thrombocytopenia, increased PT and PTT, increased bleeding time, increased D-dimer, and decreased factor V concentrations

Answer 27

Associated with pregnancy Can worsen with sun exposure Topical treatment with depigmenting agents such as hydroxyquinone may be used in severe cases.

Answer 28

Surgery and drainage Risk factors for breast abscess formation as a complication of puerperal mastitis include breastfeeding, advanced age (> 30 years), primiparity, and positive smoking history. Breast abscess without skin necrosis > fine needle aspiration.

Answer 29

Raloxifene is a selective estrogen receptor modulator (SERM) that is used to treat osteoporosis in patients who also require breast cancer prophylaxis. Indicated in the treatment of osteoporosis in patients with contraindications to bisphosphonates or postmenopausal women who also benefit from breast cancer prophylaxis. The most severe adverse effect is an increased risk of thromboembolism. Raloxifene prevents bone resorption by acting as an estrogen agonist in the bone. At the same time, it has estrogen antagonist qualities in the breast and endometrium. Also causes increased lipids.

Answer 30

A type of selective estrogen receptor modulator (SERM) that is used in breast cancer prevention and treatment. It has antiestrogenic effects in the breast and estrogenic effects in the uterus and bone.

Answer 31

SE: mandibular necrosis

Answer 32

A low lecithin-sphingomyelin ratio in amniotic fluid (< 1.5) indicates fetal lung immaturity, placing the fetus at increased risk of neonatal respiratory distress syndrome. Other amniotic fluid markers of fetal lung immaturity include a low foam stability index (< 0.48) and a low surfactant-albumin ratio.

Answer 33

Visualized on ultrasound as multiple intramural masses. The goal of preoperative therapy in a patient with leiomyoma is to decrease the size of the leiomyomatous uterus and to correct anemia by decreasing blood loss. Leuprolide before surgery

Answer 34

A GnRH agonist (e.g., leuprolide) is prescribed for patients with large and/or multiple uterine leiomyomas 2–3 months prior to surgery. GnRH agonists can reduce the size of leiomyomas by inducing hypoestrogenism and hypoprogesteronism. A reduction in the size of a leiomyomatous uterus decreases surgical time, speeds up postoperative recovery, and may even enable a vaginal hysterectomy (which typically causes less blood loss than an abdominal hysterectomy). GnRH agonists also treat menorrhagia by inducing amenorrhea, which improves hemoglobin levels before surgery.

Answer 35

Findings consistent with hemolysis (i.e., anemia, elevated total bilirubin, elevated lactate dehydrogenase, blood smear with schistocytes), elevated liver enzymes (ALT, AST), and thrombocytopenia in a pregnant woman establish the diagnosis of HELLP syndrome. This condition is typically associated with hypertension of pregnancy and preeclampsia, although 15% of affected patients are normotensive.

Answer 36

Call-Exner bodies (granulosa cells resembling primordial follicles) A granulosa cell tumor is the most common type of sex cord-stromal tumor and is associated with elevated estrogen and/or progesterone production. Granulosa cell tumors produce aromatase, which converts testosterone to estradiol. Excess production of estrogen can cause breast tenderness and menstrual abnormalities, as seen in this patient. Unopposed estrogen causes the endometrium to proliferate, resulting in abnormal uterine bleeding and an increased risk of endometrial adenocarcinoma.

Answer 37

CA 125 is a tumor marker for epithelial ovarian tumors, e.g., serous cystadenocarcinoma, which is the most common type of malignant ovarian tumors. Serous cystadenocarcinomas are most commonly located bilaterally, as opposed to this patient's unilateral adnexal mass. Moreover, histologic examination of serous cystadenocarcinoma would rather show psammoma bodies, not Call-Exner bodies.

Answer 38

Pathologically elevated β-hCG levels are seen in certain gynecological conditions, such as choriocarcinomas and dysgerminomas. Patients with choriocarcinoma often have a history of hydatidiform mole and ultrasound would show destructive growth into the uterine myometrium. Dysgerminomas can also present as an adnexal mass. However, histologic examination of dysgerminomas would rather show cells with a fried-egg appearance (clear cytoplasm and a large central nucleus), not Call-Exner bodies.

Answer 39

Atrialization of right ventricle Ebstein anomology

Answer 40

Meningocele/neural tube defects Folate absorption

Answer 41

Vaginal clear cell carcinoma

Answer 42

Patients with red flags for nipple discharge should be evaluated with imaging studies for lactiferous duct pathologies. Patients > 30 years of age should undergo ultrasonography AND diagnostic mammography to detect signs of ductal abnormalities (e.g., dilated ducts, ductal mass/nodule). For patients < 30 years of age, subareolar breast ultrasound is the preferred imaging modality; because breast tissue density is higher in this age group, a mammogram is less effective at detecting small lesions

Answer 43

The evaluation of primary amenorrhea starts with a physical examination for secondary sexual characteristics, a pelvic ultrasound to assess the internal genitalia, and a pregnancy test to rule out pregnancy. In patients with a uterus present on ultrasound, the assessment of FSH and LH levels is the next diagnostic step.

Answer 44

Meconium aspiration

Answer 45

PTU first trimester Methimazole second and third trimester

Answer 46

An amniotic fluid index ≤ 5 is consistent with oligohydramnios, which increases the risk of complications such as umbilical cord compression.

Answer 47

A 75 g oral glucose tolerance test (OGTT) is indicated at 6–12 weeks postpartum for all women with a history of gestational diabetes and a fasting serum glucose level of < 126 mg/dL after delivery. If OGTT is normal, a follow-up test (fasting glucose, HbA1c, or OGTT) should be performed every 3 years. In addition, healthy lifestyle behaviors (e.g., regular exercise, healthy diet, and weight loss) should be discussed. If the fasting serum glucose level is > 126 mg/dL after delivery or serum glucose level is ≥ 200 mg/dL 2 hours after the postpartum OGTT, T2DM can be diagnosed and should be treated accordingly

Answer 48

Vesicovaginal fistula

Answer 49

This patient's history of multiple vaginal infections, persistent urinary incontinence that worsened after a difficult delivery, a scar on the anterior vaginal wall, and a positive double dye test. Obstructive labor risk factor.

Answer 50

granulosa tumor > aromatase which converts T to E > excessive E > endometrial proliferation > risk of developing endometrial adenocarcinoma. Elevated inhibin (produced by granulosa cells). Granulosa cell tumors > Call exner bodies.

Answer 51

Hydralazine, nifedipine, labetolol

Answer 52

Preeclampsia with severe features can be diagnosed in patients at > 20 weeks' gestation who present with systolic blood pressure ≥ 160 mm Hg or diastolic blood pressure ≥ 110 mm Hg

Answer 53

HPV strains 6 and 11 cause 90% of genital warts, or condylomata acuminata

Answer 54

15–22 weeks' gestation Decreased levels of free estriol and AFP suggest numerical abnormalities of the fetal chromosomes. β-HCG is also elevated in trisomy 21, decreased in trisomy 18.

Answer 55

The ultrasound assessment of the fluid-filled area in the posterior fetal neck. Measurement of this space may be used for prenatal genetic screening. A NT ≥ 3 mm or > 99th percentile for a specified crown-rump length measurement is associated with fetal aneuploidies (e.g., Down syndrome) and congenital anomalies.

Answer 56

Down's syndrome (Trisomy 21)

Answer 57

Patau syndrome (Trisomy 13).

Answer 58

Turner's syndrome (45 XO)

Answer 59

A decrease in all quad screen markers is also consistent with trisomy 18 (Edwards syndrome), though inhibin A can also be normal in this condition. Ultrasound findings typical of Edwards syndrome include rocker-bottom feet and clenched fists with overlapping of the third and fourth digits by the second and fifth digits.

Answer 60

An isolated increase in α-fetoprotein during pregnancy is characteristic of fetal neural tube defects or open abdominal wall defects such as gastroschisis or omphalocele

Answer 61

hyperthermia, muscle rigidity, bradyreflexia, altered mental status, autonomic instability (tachycardia, hypertension) in combination with laboratory studies showing leukocytosis, increased transaminases, and elevated creatine kinase, suggest neuroleptic malignant syndrome (NMS). Haldol, anti-emetics like metoclopromide. Fluid resuscitation, administration of dopamine agonists (e.g., bromocriptine) and/or dantrolene can be considered.

Answer 62

DHEA-S is an androgen precursor that is produced by sulfation of DHEA in the adrenal cortex; elevated DHEA-S levels help to differentiate between adrenal and ovarian tumors in patients with hyperandrogenism

Answer 63

Protamine sulfate

Answer 64

Tocolysis (e.g., with indomethacin) is used to delay the onset of labor for up to 48 hours so that antenatal corticosteroids can be administered to preterm fetuses. However, tocolysis is contraindicated if cervical dilation is already greater than 4 cm and/or the fetus has lethal congenital abnormalities.

Answer 65

Facial nerve palsy

Answer 66

Transvaginal cervical cerclage is indicated for pregnant individuals with cervical insufficiency who are at < 24 weeks' gestation to help prevent pregnancy loss and preterm birth. Contraindications to cervical cerclage include premature rupture of membranes, infection (e.g., chorioamnionitis), and unexplained vaginal bleeding. In patients with cervical insufficiency and bulging membranes, cervical cerclage carries a higher risk of complications such as membrane rupture and intraamniotic infection and is typically not recommended.

Answer 67

Cervical motion tenderness, fever, pain, bloody cervical discharge, leukocytosis, increased ESR. A complication of PID Other PID complications: ectopic pregnancy, infertility, Fitz-Hugh-Curtis syndrome.

Answer 68

Painless vaginal bleeding in late pregnancy should always raise suspicion for placenta previa, especially in a woman with multiple risk factors such as increased maternal age (> 35 years), multiparity, and previous cesarean sections. Can use transvaginal ultrasound. Don't do digital exam

Answer 69

A Kleihauer-Betke test is performed in cases of suspected fetal-maternal hemorrhage (FMH). FMH typically manifests with decreased or absent fetal movements, late decelerations, or fetal tachycardia. The mother may also have fever, chills, and nausea. This patient's presentation does not raise concern for fetal-maternal hemorrhage.

Answer 70

A contraction stress test (CST) is performed for evaluating the fetal heart rate response to uterine contractions. Placenta previa, which is what this patient likely has, as well as vasa previa and previous cesarean sections are relative contraindications to a CST.

Answer 71

Multiple gestation, which is confirmed by the presence of multiple heartbeats on ultrasound, is a strong risk factor for developing hyperemesis gravidarum due to the elevated levels of hCG and progesterone. Women with a history of migraines or motion sickness are more likely to develop hyperemesis gravidarum

Answer 72

STILL PENICILLIN EVEN WITH ALLERGY Can use ceftriaxone/azithryomycin as alternative if not pregnant.

Answer 73

RF: ascending infection (most common), polyhydramnios.

Answer 74

Hypertension is a risk factor for placental abruption, preterm delivery, and small for gestational age infants. Although placental abruption also has a sudden onset, clinical findings typically include abdominal pain, vaginal bleeding, uterine tenderness, and a nonreassuring fetal heart rate pattern,

Answer 75

pH > 4.5, gray/milky discharge, amine test

Answer 76

vulvovaginal cadidas, chunky white discharge

Answer 77

Gonorrhea, chlamydia

Answer 78

Doxycycline is the preferred treatment for chlamydial infection in nonpregnant patients but is contraindicated during pregnancy because it may lead to bone damage and tooth staining in the child. A single dose of oral azithromycin is the recommended first-line treatment for chlamydial infection in pregnant patients

Answer 79

Ceftriaxone

Answer 80

Obstetric anal sphincter injury (OASI) is one of the most common causes of fecal incontinence in women. OASI occurs as a result of perineal lacerations that involve the anal sphincter complex (i.e., third and fourth-degree lacerations), leading to a decreased anal sphincter tone. Risk factors for this condition include prolonged labor, operative vaginal delivery, fetal macrosomia, and episiotomy. Most individuals with OASI develop symptoms of anal insufficiency (e.g., fecal incontinence) weeks after delivery. The absence of perianal folds in the perianal region (dovetail sign) is characteristic of delayed OASI. The diagnosis of OASI is typically confirmed by endoanal ultrasound.

Answer 81

a condition mainly seen in women with a history of hypertension, multiparity, and previous cesarean delivery. hypovolemic shock (maternal tachycardia, hypotension, and cool, clammy extremities), fetal distress (fetal bradycardia, in this case), and a rigid/woody, tender uterus on palpation

Answer 82

painless, bright red vaginal bleeding after the rupture of membranes. The hemorrhage is mainly of fetal origin, resulting in fetal distress

Answer 83

SOFT uterus

Answer 84

A central mass with hypoechoic spaces on ultrasonography, the absence of fetal heart sounds, a fundus that is larger in size than the gestational age, and highly elevated beta-hCG levels (> 100,000 mIU/mL) indicates a complete hydatidiform mole, a form of benign gestational trophoblastic disease (GTD). The highest incidence of GTD is seen in Taiwan and the Philippines. Manifestations of GTD include vaginal bleeding, hyperemesis gravidarum, and early-onset preeclampsia (gestational hypertension with proteinuria).

Answer 85

physiological changes of pregnancy (peripheral edema, shortness of breath, fatigue, and a third heart sound

Answer 86

Virilization This patient's symptoms of virilization (e.g., oligomenorrhea, hirsutism, male pattern baldness, acne, and clitoral enlargement) in combination with increased serum testosterone and an ovarian mass on ultrasound raise suspicion for a Sertoli-Leydig cell tumor. Sertoli-Leydig cell tumors are rare ovarian sex cord-stromal tumors characterized by androgen-producing testicular structures. They are most commonly found in women aged 30–40 and may be malignant or benign. Treatment consists of surgical excision and in some cases adjuvant chemotherapy.

Answer 87

Adolescents/young women A biopsy characteristically shows undifferentiated germ cells with a clear cytoplasm known as “fried egg” cells.

Answer 88

A biopsy characteristically shows psammoma bodies and fallopian tube epithelium with papillary folds. Typical ovarian cyst.

Answer 89

Benign, post menopausal women abnormal uterine bleeding due to estrogen-induced endometrial stimulation, as opposed to the virilization and increased serum testosterone seen in this patient. A biopsy characteristically shows stromal hyperplasia.

Answer 90

potentially malignant ovarian sex cord-stromal tumors that express aromatase, leading to increased conversion of testosterone to estrogen. The most common presentation is postmenopausal bleeding or precocious puberty caused by hyperestrogenism, A biopsy characteristically shows Call-Exner bodies.

Answer 91

oligomenorrhea, features of hyperandrogenism (hirsutism, acne vulgaris, elevated testosterone), and elevated LH:FSH ratio (≥ 2:1) indicate polycystic ovary syndrome (PCOS). Transvaginal ultrasound may be performed to identify cystic follicles and assess ovarian volume but is not required to establish the diagnosis of PCOS if ovulatory dysfunction and hyperandrogenism are present.

Answer 92

The most important mechanism of action of combined oral contraceptives in preventing ovulation is the inhibition of the LH surge. The estrogen and progestin in combined OCPs provide negative feedback to the hypothalamus, preventing the release of GnRH and, subsequently, both FSH and LH. This decreased gonadotropin secretion prevents the spike in estrogen (released from the Graafian follicle) necessary to induce the LH surge in the pituitary, which then initiates ovulation. This significantly reduces the possibility of successful fertilization (< 1% with perfect use; 9% with typical use). OCPs are contraindicated in women who have migraines with aura, smoke cigarettes above the age of 35 years, or have a history of stroke, thromboembolism, breast cancer, or liver disease.

Answer 93

In pregnant women with high-grade precancerous lesions (i.e., CIN2 or CIN3), colposcopic surveillance with HPV-based testing every 12–24 weeks is preferred. Deferring colposcopy until ≥ 4 weeks after delivery is also an acceptable approach. The management of pregnant individuals with high-grade lesions differs from that of nonpregnant patients: treatment of premalignant lesions can safely be deferred until the postpartum period; expedited treatment for HSIL is contraindicated during pregnancy. A repeat biopsy should be performed if the cervical lesion appears to be worsening on colposcopic surveillance. An excisional procedure should be considered only if invasive cancer is suspected.

Answer 94

Cold-knife conization is used in the management of high-grade cervical abnormalities and early-stage cervical cancer. Cold-knife conization is contraindicated during pregnancy but can be safely performed 4 weeks after birth. However, before any cervical excision procedure, repeat colposcopic evaluation needs to re-confirm the need for excision

Answer 95

after 20 weeks

Answer 96

Systolic blood pressure (SBP) of 140–159 mm Hg and diastolic blood pressure (DBP) of 90–109 mm Hg without thrombocytopenia, transaminitis, renal insufficiency, pulmonary edema, abdominal pain, visual disturbances, or treatment-refractory headache indicates preeclampsia without severe features

Answer 97

If the patient develops preeclampsia with severe features, she should be admitted to the hospital for antihypertensive therapy with intravenous hydralazine, intravenous labetalol, or oral nifedipine; eclampsia prophylaxis with magnesium sulfate; and antenatal corticosteroid therapy. Delivery should be considered after stabilization.

Answer 98

Sjorgen syndrome: Anti-Ro/SSA antibodies and anti-La/SSB antibodies

Answer 99

Asherman syndrome (AS). AS most commonly occurs following intrauterine instrumentation (e.g., dilation and curettage) and may manifest with infertility, secondary amenorrhea, and cyclic pelvic pain (due to blood accumulation in the uterus). Serum concentrations of FSH, LH, and prolactin are typically within the reference ranges. AS is usually asymptomatic; the standard treatment for symptomatic AS is hysteroscopic resection of the adhesions.

Answer 100

The workup of secondary amenorrhea includes a progestin and/or an estrogen/progestin withdrawal test, which induces withdrawal bleeding in patients with anovulatory cycles (e.g., due to polycystic ovary syndrome, primary ovarian insufficiency). Because of the presence of intrauterine adhesions and blocked outflow tract, these tests do not cause bleeding in patients with AS.

Answer 101

Dopamine receptor agonists such as cabergoline or bromocriptine are first-line treatments for all prolactinomas. By decreasing prolactin secretion they improve symptoms due to hyperprolactinemia such as galactorrhea, irregular menses, or vaginal atrophy

Answer 102

Pelvic floor therapy

Answer 103

Arrest of fetal descent for > 2 hours in multiparous patients (or > 3 hours in those who have received an epidural) is consistent with prolonged second stage of labor.

Answer 104

Operative vaginal delivery (forceps delivery or vacuum-assisted delivery) is indicated for prolonged second stage of labor in women with adequate uterine contractions and an engaged fetal head. Cesarean delivery should be performed if the fetal head is not engaged. Augmentation of labor (e.g., with oxytocin) can be considered if the fetal head is engaged but maternal contractions are inadequate.

Answer 105

Regular, heavy menstrual bleeding and dysmenorrhea in a multiparous woman with a uniformly enlarged and tender uterus. Ectopic endometrial tissue within the myometrium is characteristic of uterine adenomyosis, which has a peak incidence between 40 and 50 years of age. The ectopic endometrial tissue induces hypertrophy and hyperplasia of the surrounding myometrium and results in a symmetrically enlarged uterus similar to a uterus in pregnancy. Secretions from ectopic glands within the myometrium cause pain and cramping, which become worse during menses.

Answer 106

The first-line treatment for acute uncomplicated cystitis in nonpregnant women is trimethoprim/sulfamethoxazole (TMP/SMX). Alternative first-line treatments include nitrofurantoin and fosfomycin.

Answer 107

https://next.amboss.com/us/article/580iM3#Z12caf4386d9001e1ea5dbc1592e6da4f

Answer 108

A complete molar pregnancy can cause abdominal pain and vaginal bleeding. However, ultrasonography in a complete molar pregnancy would show no evidence of fetal parts and an echogenic mass interspersed with many hypoechogenic cystic spaces that represent diffuse hydropic villi. In addition, β-hCG concentration and uterine size in a complete molar pregnancy are typically much greater than those expected for gestational age

Answer 109

Abdominal pain and vaginal bleeding during the first trimester, and the finding of cystic spaces within the placenta are consistent with a hydatidiform mole (molar pregnancy), which is characterized by abnormal proliferation of trophoblastic tissue and the presence of hydropic (edematous) chorionic villi. Unlike a complete hydatidiform mole, which causes diffuse trophoblastic proliferation without evidence of fetal parts and extensive hydropic villi formation, a partial hydatidiform mole causes focal trophoblastic proliferation with few hydropic villi and is associated with the presence of fetal parts. In approx. 50% of patients with a complete mole, the uterine size is large for gestational age whereas the uterine size is small or normal for gestational age in patients with a partial mole. In a normal gestation, β-hCG concentration doubles every 2.5 days during the first 4 weeks and peaks at 8–10 weeks with a value of approx. 100,000 mlU/mL. In a complete mole, β-hCG concentration is typically much greater than the value expected for gestational age; in a partial mole, β-hCG concentration is similar to the value expected with normal gestation or only slightly more elevated. When compared to complete moles, partial moles have a lower risk of malignant transformation to gestational trophoblastic neoplasia as well as a lower risk of medical complications (e.g., hyperemesis gravidarum, early-onset preeclampsia, acute respiratory distress syndrome). To prevent malignant transformation, management for all hydatidiform moles consists of a dilation and curettage to remove the trophoblastic tissue and serial β-hCG monitoring to ensure complete removal. In unresolved cases, chemotherapy (typically with methotrexate) is indicated.

Answer 110

This patient's sudden onset of painless vaginal bleeding and the absence of fetal distress are concerning for placenta previa, the most common cause of painless vaginal bleeding in the third trimester. Placenta previa is not associated with fetal distress because the bleeding is from the maternal circulation. The diagnosis of placenta previa is made using transabdominal and transvaginal ultrasound that shows the attachment of the lower edge of the placenta < 2 cm from the internal cervical os. Risk factors for this condition include multiparity, prior Cesarean sections, age over 35 years, and smoking.

Answer 111

Magnesium Sulfate

Answer 112

Potter sequence A collection of fetal abnormalities caused by oligohydramnios. The classical triad of Potter sequence is craniofacial abnormalities, clubbed feet, and pulmonary hypoplasia. The prognosis of patients born with Potter sequence depends on the root cause of oligohydramnios but the condition is often deadly due to pulmonary hypoplasia.

Answer 113

Letrozole for ovulation induction is a first-line pharmacotherapy for patients with PCOS who wish to conceive. By inhibiting aromatase, letrozole reduces estrogen production, stimulating FSH secretion and thus inducing ovulation. Obesity can contribute to increased estrogen secretion and hyperinsulinemia, which are the underlying causes of LH and FSH imbalances that lead to impaired follicle maturation and consequent oligoovulation or anovulation. Therefore, patients with obesity should be advised on lifestyle modifications aimed at weight loss. In patients with insulin resistance, metformin may be added to the treatment regimen

Answer 114

Poor weight gain and stridor are serious neonatal manifestations that may be seen in untreated maternal Graves disease. During pregnancy, TSH receptor antibodies cross the placenta, leading to neonatal Graves disease and thyrotoxicosis. Neonatal thyrotoxicosis is most often self-limiting, but severe disease can result in tachycardia, diaphoresis, failure to thrive, hyperphagia, stridor (due to compressive goiter), and microcephaly (attributable to craniosynostosis)

Answer 115

The hyperestrogenic state during pregnancy stimulates the synthesis of thyroid-binding globulin (TBG) by the liver and increases the glycosylation of TBG. This process slows the clearance of TBG, increasing its serum level. As more free T3 and T4 bind to TBG, the level of free thyroid hormones decreases. Consequently, the pituitary gland secretes more TSH, resulting in increased synthesis and secretion of thyroid hormones. This achieves a new equilibrium in which the total T3 and T4 levels (i.e., bound and unbound T3 and T4) are increased, while the free T3 and T4 levels are normal. These changes also occur in women taking oral contraceptives or hormone replacement therapy, and in patients with estrogen-producing tumors.

Answer 116

di di pregnancy

Answer 117

Monochorionic diamniotic

Answer 118

Although patients with adenomyosis may also be asymptomatic like this patient, the characteristic palpatory finding of adenomyosis is that of a uniformly enlarged uterus

Answer 119

Long thoracic nerve

Answer 120

Thoracodorsal nerve

Answer 121

IUGR, affects placental growth

Answer 122

Methyldopa is a centrally acting alpha-2 adrenergic agonist that is safe for use in pregnancy Other are nifedipine, labetalol, or hydralazine

Answer 123

Hypertension, short stature, low-set posterior hairline, shield chest, and numerous pigmented nevi in a patient with a history of primary amenorrhea suggests Turner syndrome. Horseshoe kidney and streak gonads, both of which are seen here, are common findings in individuals with this condition Cardiac changes: most commonly bicuspid aortic valve and coarctation of the aorta. Because these anomalies increase the risk of early death, regular cardiac assessment with cardiac MRI or transthoracic echocardiography is recommended to detect and monitor structural anomalies. Patients with Turner syndrome should also receive regular screening for other commonly associated c

Answer 124

ERBB2-positive tumors respond well to targeted therapy with trastuzumab and chemotherapeutic agents such as anthracyclines and taxanes. Before initiating treatment, an echocardiogram should be performed to evaluate cardiac function, since trastuzumab, anthracyclines, and taxanes are cardiotoxic (e.g., cause dilated cardiomyopathy with systolic congestive heart failure). The cardiotoxic effects may be limited with dexrazoxane, an iron-chelating agent.

Answer 125

In the United States, guidelines recommend that all Rh-negative mothers who may potentially be carrying an Rh-positive fetus undergo anti-D antibody screening at the first prenatal visit. If the first anti-D screen shows that the mother is unsensitized, she should undergo repeat screening between 24 and 28 weeks' gestation. If the anti-D screen remains negative, RhoGAM should be administered at 28 weeks' gestation (typically a single standard dose without confirmation of the fetal blood type) and, if the newborn is Rh-positive, again within 72 hours following delivery after fetomaternal hemorrhage tests to determine the dosage.

Answer 126

Choriocarcinoma A highly malignant gestational trophoblastic neoplasia (GTN) characterized by invasive, highly vascular, and anaplastic trophoblastic tissue without villi. It is rare but can arise from any type of trophoblastic tissue (molar pregnancy, abortion, ectopic, prior pregnancy). It has the propensity to metastasize to the lungs, vagina, CNS, liver, kidney, and GI tract. Bleeding from these metastatic sites is common

Answer 127

Estrogen found within COCs decreases protein S levels. Since protein S is an essential cofactor for protein C, which inactivates procoagulant factors Va and VIIIa, reduction of protein S results in an increased risk for thrombus formation and the development of DVTs.

Answer 128

Punch biopsy

Answer 129

TVUS may not reliably detect an intrauterine pregnancy before 5 weeks' gestation or before serum β-hCG is > 1500–2000 mIU/mL

Answer 130

Mefloquine

Answer 131

Olestemivir

Answer 132

Chancroid is a sexually transmitted infection caused by the gram-negative bacillus Haemophilus ducreyi. In women, chancroid manifests with multiple purulent lesions that are 1–2 cm in size, clearly demarcated with a greyish necrotic base, and typically very painful. In men, a single lesion is common. In addition, chancroid is often accompanied by pain

Answer 133

Substance use in pregnancy/breast feeding

Answer 134

Raloxifene prevents bone resorption by acting as an agonist on estrogen receptors in the bone. At the same time, it acts as an estrogen antagonist in the breast and endometrium. The most severe adverse effects of raloxifene are thromboembolic events, such as deep venous thrombosis, pulmonary embolism, and retinal vein thrombosis. Raloxifene is therefore contraindicated in women with a history of or current venous thromboembolic disorders.

Answer 135

This patient can deliver her baby by vaginal delivery because her serum studies are consistent with successful vaccination against HBV, as indicated by her positive anti-hepatitis B surface antigen antibody, negative hepatitis B core antigen, and negative hepatitis B surface antigen results. Her positive anti-hepatitis A virus (HAV) and IgG antibody (anti-HAV IgG) and negative Anti-HAV IgM antibody results indicate either HAV vaccination or past infection. Even if the mother had active HAV or HBV, spontaneous vaginal delivery, rather than cesarean delivery, would be recommended.

Answer 136

Antibiotic prophylaxis with ampicillin and azithromycin is recommended in all patients with PPROM at < 34 weeks' gestation to decrease the risk of bacterial infections in both the mother and newborn. Antenatal corticosteroids (e.g., betamethasone, dexamethasone) are also indicated to induce fetal lung maturation. If both mother and newborn are stable, tocolytics (e.g., NSAIDs, beta-adrenergic agonists, calcium-channel blockers) can be used, if necessary, to delay delivery for 48 hours to allow more time for lung maturation. In preterm patients who are at > 34 weeks' gestation, expectant management and induction of labor are both reasonable options; the decision should be made on an individual basis. Fetal outcome is generally poor before or at the limit of viability; therefore, expectant management may be carried out in patients who are at < 24 weeks' gestation.

Answer 137

an obstetric emergency that most commonly occurs in the third trimester and is the most common cause of acute hepatic failure during pregnancy. AFLP has a large clinical overlap with hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome but features such as hypoglycemia, leukocytosis, severe hyperbilirubinemia, and acute hepatic failure are more common with AFLP than HELLP syndrome while hypertension and proteinuria are more common with HELLP syndrome than AFLP. Given the risk of severe fetal and maternal complications associated with AFLP, prompt delivery is indicated.

Answer 138

Individuals with lichen sclerosus have an increased risk of developing vulvar squamous cell carcinoma. Because the results of this patient's biopsy are negative for malignancy, the next step in management is to administer superpotent topical glucocorticoids, such as betamethasone or clobetasol, which help reduce inflammation and pruritus.

Answer 139

Diethylstilbestrol (DES) is a synthetic estrogen that was introduced in the 1940s as it was believed to prevent miscarriage in pregnant women. In 1971, DES was discontinued because studies found that it is a potent transplacental carcinogen. It significantly increases the lifetime risk of vaginal clear cell adenocarcinoma, a rare form of vaginal cancer, in daughters of the women who received DES. Therefore, women with a history of intrauterine DES exposure should be monitored closely.

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