OB/GYN Shelf Review

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1. A 17-year-old G1P0 female at 39 weeks presents with
increased swelling in her face and hands over the last two
days. Her blood pressure is 155/99. She has 2 plus pitting
edema of the lower extremities. A 24-hour urine collection
shows 440 mg of protein. What is the next best step in the
management of this patient?
A. Fluid restriction
B. Magnesium sulfate
C. Furosemide
D. Hydralazine
E. Delivery
2. An 18-year-old G1 woman at 32 weeks gestation presents
with severe abdominal pain and a small amount of
bleeding. She has received routine prenatal care, smokes
one pack of cigarettes per day and admits to using crack
cocaine. On exam, her blood pressure is 140/80, pulse 100
and she is afebrile. Her uterus is tense and very tender.
Pelvic ultrasound reveals a fundal placenta, cephalic
presentation of the fetus and no other abnormalities.
Cervical examination reveals blood coming through the os
and is one centimeter dilated. Fetal heart tones have a
baseline of 160s, with a category III tracing. Which of the
following is the most likely diagnosis?
Correct answer is E. This patient has a diagnosis of preeclampsia.
Delivery is recommended for women with gestational hypertension or
preeclampsia without severe features at or beyond 37 0/7 weeks of
gestation. Fluid management must be monitored closely in this person
as patients with preeclampsia are at risk for developing pulmonary
edema. Treatment with magnesium sulfate is not recommended for
women with preeclampsia with systolic BP of less than 160 mm Hg and
a diastolic BP less than 110 mm Hg and no maternal symptoms.
Diuretics should not be administrated to this patient as it might further
deplete her intravascular volume, but may be indicated in the setting
of pulmonary edema. Treatment with antihypertensive agents is not
indicated for patients with preeclampsia with a persistent BP of less
than 160 mm Hg systolic or 110 mm Hg diastolic.
This patient has a placental abruption. Common presenting signs of an
abruption include abdominal pain, bleeding, uterine hypertonus and
fetal distress. Risk factors include smoking, cocaine use, chronic
hypertension, trauma, prolonged premature rupture of membranes,
and history of prior abruption. Treatment would involve an emergent
Cesarean section with appropriate resuscitation, including intravenous
fluids and blood products as needed. A placenta previa is an
abnormal location of the placenta.

A. Placenta previa
B. Premature rupture of the membranes
C. Preterm labor
D. Placental abruption
E. Chorioamnionitis
3. A 19-year-old G2P1 African American woman at 30 weeks The primary risk factor for preterm rupture of membranes is genital
gestation presents with preterm rupture of membranes six tract infection, especially associated with bacterial vaginosis. All of the
hours ago. Her prenatal course has been complicated by other listed options are risk factors. Smoking and prior preterm
two episodes of bacterial vaginosis for which she was premature rupture of membranes (which she did not have previously
treated. She takes prenatal vitamins and iron. She denies because she delivered at 41 weeks) increases the likelihood of preterm
substance abuse or alcohol use, but admits to smoking five rupture of membranes two-fold. A shortened cervical length is also a
cigarettes each day. Her prior pregnancy was delivered risk factor, but her cervical length is normal.
vaginally at 41 weeks after spontaneous rupture of
membranes. Her blood pressure is 110/70; pulse 84;
temperature 98.6F (37.0C). Pertinent sonographic findings
reveal oligohydramnios and a cervical length of 30 mm.
Which of the following is the most likely cause of preterm
premature rupture of membranes in this patient?
A. Ethnicity
B. Smoking
C. Previous premature rupture of membranes
D. Cervical length
E. Genital tract infections
4. A 20-year-old G1 woman at 40 weeks gestation
presents to labor and delivery complaining of painful
contractions every 3-4 minutes since midnight. Her
examination on admission was 2 centimeters dilated,
90% effaced and 0 station. Three hours later, her exam
is unchanged. The patient is still having contractions
every 3-4 minutes. She is discouraged about her lack
of progress. Which of the following is the most
appropriate next step in the management of this
patient?
A. Laminaria placement
B. Artificial rupture of membranes
C. Counseling about latent phase of labor and rest
D. Manual cervical dilation
E. Cesarean section for arrest of labor
5. A 23-year-old G1P1 woman delivered her first baby two
days ago after an uncomplicated labor and vaginal
delivery. She wants to breastfeed and has been
working with the lactation team. Prior to discharge, her
temperature was 100.4 F (38 C) and other vitals were
normal. She denies urinary frequency or dysuria and
her lochia is mild without odor. On examination, her
lungs are clear, cardiac exam normal, and abdomen
and uterine fundus are nontender. Her breasts are firm
and tender throughout, without erythema, and nipples
are intact. Which of the following is the most likely
cause of her fever?
A. Endomyometritis
B. Septic pelvic thrombophlebitis
C. Mastitis
D. Breast engorgement
E. Vaginitis
6. A 24-year-old G1P0 at 32 weeks gestation presents
with vaginal bleeding most likely caused by placental
abruption. She receives a standard dose of 300
micrograms of RhoGAM. What amount of fetal blood is
neutralized by this dose?
A. 10 cc
B. 20 cc
C. 30 cc
D. 40 cc
E. 50 cc
7. A 24-year-old G2P1 woman has a fetus that is affected
by Rh disease. At 30 weeks gestation, the delta OD450
(optical density deviation at 450 nm) results plot on the
Liley curve in Zone 3 indicating severe hemolytic
disease. Which of the following is the most appropriate
next step in the management of this patient?
A. Immediate Cesarean delivery
B. Induction of labor
C. Intrauterine intravascular fetal transfusion
D. Umbilical blood sampling
E. Maternal plasmapheresis
Correct answer is C. The patient is in the latent phase of labor and has not
yet reached the active phase (more than 4 cm). A prolonged latent phase
is defined as >20 hours for nulliparas and >14 hours for multiparas, and may
be treated with rest or augmentation of labor. Artificial rupture of
membranes is not recommended in the latent phase as it places the patient
at increased risk of infection. Cervical dilation or laminaria placement are
not indicated.
Correct answer is D. Breast engorgement is an exaggerated response to
the lymphatic and venous congestion associated with lactation. Milk "let-
down" generally occurs on postpartum day two or three. If the baby is not
feeding well, the breast can become engorged, which can cause a low-
grade fever. Lactating women are encouraged to feed their baby
frequently, and use a breast pump to prevent painful engorgement and
mastitis. Postpartum fever differential includes endometritis, cystitis and
mastitis. These are easy distinguished, based on clinical findings. Vaginitis is
not accompanied by fever. Septic pelvic thrombophlebitis is a rare
condition and characterized by high fever not responsive to antibiotics and
is a diagnosis of exclusion.
Correct! 30 cc of fetal blood is neutralized by the 300 micrograms dose of
RhoGAM. This is equivalent to 15 cc of fetal red blood cells. At 28-weeks
gestation, 300 micrograms of Rh-immune globulin is routinely administered
after testing for sensitization with an indirect Coombs' test. Administration
is given following amniocentesis at any gestational age.
Correct answer is C. Values in Zone 3 of the Liley curve indicate the
presence of severe hemolytic disease, with hydrops and fetal death likely
within 7-10 days, thus demanding immediate delivery or fetal transfusion. At
30 weeks gestation, the fetus would benefit from more time in utero. An
attempt should be made to correct the underlying anemia. Intravascular
transfusion into the umbilical vein is the preferred method. Intraperitoneal
transfusion is used when intravascular transfusion is technically impossible.
If fetal hydrops is present, the reversal of the fetal anemia occurs much
more slowly via intraperitoneal transfusion. Percutaneous umbilical blood
sampling should not be used as a first-line method to evaluate fetal status.
Maternal plasmapheresis is used in severe disease when intrauterine
transfusions are not possible.
8. A 24-year-old G2P1 woman is diagnosed with Rh hemolytic
disease at 24 weeks gestation. Measurement of which of the
following in the amniotic fluid is best indicative of the severity
of the disease?
A. Hemoglobin
B. Iron
C. Anti-D antibody titer
D. Glucose
E. Bilirubin
9. A 24-year-old Rh-negative G1P1 woman just delivered a
healthy term infant who is Rh-positive. You recommend
RhoGAM administration but she declines because she does
not desire any blood products. What is her approximate risk
of isoimmunization if she does not receive the RhoGAM?
Correct! In the presence of a severely erythroblastotic fetus, the
amniotic fluid is stained yellow. The yellow pigment is bilirubin,
which can be quantified most accurately by spectrophotometric
measurements of the optical density between 420 and 460nm, the
wavelength absorbed by bilirubin. The deviation from linearity of
the optical density reading at 450nm is due to the presence of
heme pigment, an indicator of severe hemolysis.
Correct answer is A.
The risk of isoimmunization is 2% antepartum, 7% after full term
delivery, and 7% with subsequent pregnancy.

A. Less than 20%

B. 40%
C. 60%
D. 80%
E. 100%
10. A 25-year-old G0 woman presents to her doctor for Smoking increases the risk of several serious complications of
preconception counseling. She is healthy without significant pregnancy, including placental abruption, placenta previa, fetal
medical problems. She takes no medications. She smokes one growth restriction, preeclampsia and infection. Women who smoke
pack of cigarettes per day since age 16 and drinks should be counseled vigorously to quit smoking prior to
occasionally. She weighs 140 pounds and her vital signs and conception and to resist restarting after the baby is born.
examination are normal. The patient is at increased risk of
which of the following during her pregnancy?
A. Fetal chromosomal abnormality
B. Breech presentation
C. Placental abruption
D. Cerebral palsy
E. Neural tubal defect
11. A 28-year-old G3P2 woman presents in labor at 39 weeks Placental abruptions, labor augmentation, degree of parity and
gestation and delivers a 3500 gram infant spontaneously circumvallate placenta have no impact on the risk of retained
after oxytocin augmentation of labor. Thirty minutes later, the placenta. The following are associated with retained placenta: prior
placenta has not delivered. Her past medical history is Cesarean delivery, uterine leiomyomas, prior uterine curettage and
significant for leiomyoma uteri. Her prenatal course was succenturiate lobe of placenta.
uncomplicated. What is the most likely risk factor for retained
placenta in this case?
A. Placental abruption
B. Labor augmentation
C. Leiomyomas
D. Multiparity
E. Circumvallate placenta
12. A 29-year-old G1P0 woman at 28 weeks gestation who is the Fetal macrosomia, maternal obesity, diabetes mellitus, postterm
wife of basketball player is diagnosed with gestational pregnancy, a prior delivery complicated by a shoulder dystocia,
diabetes. Her mother had a delivery complicated by shoulder and a prolonged second stage of labor are all associated with an
dystocia and she is concerned about her own risk. Which of increased incidence of shoulder dystocia. Although a family history
the following is her biggest risk factor for shoulder dystocia? can be indicative of large babies which might place her at
A. Family history additional risk, her gestational diabetes represents her largest risk
B. Tall husband factor.
C. Age
D. Gestational diabetes
E. Parity
13. A 29-year-old G4P2 woman was
diagnosed with twin-twin transfusion
syndrome when an ultrasound was
performed at 24 weeks gestational
age. Which of the following is a
complication of twin-twin transfusion
syndrome?
A. Fetal macrosomia in the donor
twin
B. Neurologic sequelae in the
surviving twin
C. Tricuspid regurgitation in the
donor twin
D. Heart failure in the donor twin
only
E. High perinatal mortality for donor
twin only
14. A 29-year-old G4P2 woman with no
previous prenatal care presents at
24 weeks gestation with signs and
symptoms of preterm labor. Her
cervix is 3 cm dilated and 80%
effaced. Fundal height is 30 cm and
an ultrasound examination reveals a
twin gestation. Estimated fetal
weights on the twins are 850 gm and
430 gm. The maximum vertical
amniotic fluid pocket around the
smaller twin is 1 cm; the maximum
vertical amniotic fluid pocket around
the larger twin is 8 cm. Which of the
following is the most likely
associated with these ultrasound
findings?
A. Dichorionic diamniotic twins
B. Monochorionic monoamniotic
twins
C. Monochorionic diamniotic twins
D. Superfecundation
E. Rh-isoimmunization
Correct answer is B. Untreated severe twin-twin transfusion syndrome has a poor prognosis,
with perinatal mortality rates of 70-100%. Death in utero of either twin is common. Surviving
infants have increased rates of neurological morbidity, with increased risk of cerebral palsy
for the surviving twin. Excessive volume can lead to cardiomegaly, tricuspid regurgitation,
ventricular hypertrophy and hydrops fetalis for the recipient twin. Although the recipient twin
is plethoric, it is not macrosomic. The donor twin becomes anemic and hypovolemic, and
growth is retarded. The recipient twin becomes plethoric, hypervolumic and macrosomic.
Either twin can develop hydrops fetalis. The donor twin can become hydropic because of
anemia and high-output heart failure.
Correct answer is C. Twin-twin transfusion syndrome is the result of an intrauterine blood
transfusion from one twin to the other. It most commonly occurs in monochorionic,
diamniotic twins. The donor twin is often smaller and anemic at birth. The recipient twin is
usually larger and plethoric at birth. Clues to the presence of the twin-twin transfusion
syndrome include the large weight discordance (although this is not necessary for diagnosis),
polyhydramnios around the larger (recipient) twin, and oligohydramnios around the smaller
(pump) twin. The two different placental types in twin gestation are monochorionic and
dichorionic. Monozygotic conceptions may have either monochorionic or dichorionic
placentation, depending upon the time of division of the zygote. Dizygotic conceptions
always have dichorionic placentas. Diamniotic dichorionic placentation occurs with division
prior to the morula state (within three days post fertilization). Diamniotic monochorionic
placentation occurs with division between days four and eight post fertilization.
Monoamniotic, monochorionic placentation occurs with division between days eight and 12
post fertilization. Superfecundation is the fertilization of two different ova at two separate
acts of intercourse in the same cycle. Isoimmunization is associated with polyhydramnios and
fetal hydrops and does not cause twin-twin transfusion.
15. A 30-year-old G2P1 woman with last menstrual
period 10 weeks ago presents for her first
prenatal care visit. She is healthy and takes no
medications. Her previous pregnancy was an
uncomplicated vaginal delivery at 39 weeks. On
examination, her vital signs are normal. Her
exam is notable for a uterus measuring 14
weeks gestation. Ultrasound shows a diamniotic
monochorionic twin gestation at 10 weeks.
Which of the following obstetrical
complications is more likely in this pregnancy
compared to her previous pregnancy?
A. Low maternal weight gain
B. Congenital anomalies
C. Induction after 40 weeks
D. Macrosomia
E. Rh isoimmunization
16. A 31-year-old G3P0 woman at 27 weeks is being
managed expectantly for severe preeclampsia
remote from term. Her blood pressure is
155/100 on labetalol 200 mg three times a day.
Her recent 24-hour urine had 6.6 grams of
protein. An ultrasound revealed a fetus with
adequate growth, having an estimated fetal
weight in the 10th percentile. Her labs are
normal, except for a uric acid of 8.0 mg/dL,
hematocrit of 42% (increased from 37%,) and a
platelet count of 97,000. Which of these
findings necessitates delivery at this time?
A. Elevated uric acid
B. Thrombocytopenia
C. Proteinuria
D. Poorly controlled blood pressures
E. Hemoconcentration
17. A 32-year-old G1 is seeing you in consultation
at 35 weeks gestation. Ultrasound reveals
limited fetal growth over the past three weeks.
Biometry is consistent with 30-5/7, EFW 1900 g,
less than 10th percentile. You counsel her about
short and long-term complications for her baby.
This fetus is at increased risk for all of the
following adult disorders EXCEPT:
A. Cardiovascular disease
B. Chronic hypertension
C. Chronic obstructive lung disease
D. Diabetes
E. Osteoporosis
Correct answer is B. The incidence of congenital anomalies is increased in twins,
particularly monozygotic twins, compared to singletons. The majority of twin pairs
in which an anomaly is present will be discordant for the anomaly. Twin gestations
tend to deliver earlier than singleton gestations, with the average length of twin
gestation being 35-37 weeks. The optimal length of twin gestation is a matter of
some controversy. An observational study comparing perinatal mortality among
twin and singleton gestations showed that perinatal mortality reached a nadir at
37-38 weeks in twins and then increased. There have been no prospective studies
to demonstrate that induction of labor after 38 weeks in twin gestations improves
perinatal outcome. Twins typically weigh less than singletons of the same
gestational age, but their weights usually remain within the normal range.
Macrosomia is, therefore, uncommon
Correct answer is B. Thrombocytopenia <100,000 is a contraindication to
expectant management of severe preeclampsia remote from term. Delivery is
recommended for patients diagnosed with severe preeclampsia when gestational
age is at or beyond 34 0/7 weeks. Additional contraindications to expectant
management prior to 34 weeks gestation include pulmonary edema, renal failure,
abruption- placentae, disseminated intravascular coagulation, persistent cerebral
symptoms, non-reassuring fetal testing, or fetal demise. Women with these
conditions should be delivered irrespective of gestational age.
Other contraindications include: inability to control blood pressure with maximum
doses of two antihypertensive medications, non-reassuring fetal surveillance, liver
function test elevated more than two times normal, eclampsia, persistent CNS
(central nervous system) symptoms and oliguria. Delivery should not be based on
the degree of proteinuria. Although elevated, uric acid and hemoconcentration
are markers of preeclampsia, they are not part of the diagnostic or management
criteria.
Correct answer is E. Epidemiologic studies indicate that fetal growth restriction is
a significant risk factor for the subsequent development of cardiovascular disease,
chronic hypertension, chronic obstructive lung disease and diabetes. Researchers
suggest that the phenomenon of programming may be operable and that an
adverse fetal environment during a critical period of fetal growth helps to
promote these adult diseases. Osteoporosis risk factors include family history,
slender body composition, prior history of osteoporosis, Asian and Caucasian
ethnicity, alcohol consumption, smoking, sedentary lifestyle, excess thyroid or
corticosteroids and use of anticonvulsant medications.
18. A 32-year-old G1P0 woman at 10
weeks gestation presents to your
office after an ultrasound evaluation
has revealed a diamniotic,
dichorionic twin gestation. She is very
concerned about the risk for preterm
delivery. Which intervention would
you recommend as a possible means
to reduce the risk of a preterm, low-
birthweight infant?
A. Bed rest
B. Cervical cerclage
C. Tocolytics starting at 24 weeks
D. Home uterine monitoring
E. Early, good weight gain
19. A 32-year-old G1P0 woman comes to
your office for her first prenatal care
visit. She has recently read an article
about the rising Cesarean section
rate in the United States and asks you
about the rate in your hospital. What
do you explain as the major cause of
higher Cesarean delivery rates?
Correct answer is E. Although prematurity has been recognized as a major cause of
morbidity and mortality among twin gestations, interventions for prevention of prematurity
have, in general, been unsuccessful. Studies show that an adequate weight gain in the first 20
to 24 weeks of pregnancy is especially important for women carrying multiples and may
help to reduce the risk of having preterm and low-birth weight babies. These pregnancies
tend to be shorter than singleton pregnancies, and studies suggest that a good early weight
gain aids in development of the placenta, possibly improving its ability to pass along
nutrients to the babies. Bed rest, long prescribed by obstetricians for the prevention of
preterm birth, has never been shown to be efficacious, and may be associated with
thromboembolic complications. An observational study of prophylactic cerclage for twin
gestations failed to show any benefit. Tocolytic drugs for prevention of preterm labor in
asymptomatic women with twin gestations have not been shown to be effective. Home
uterine activity monitoring is another intervention that has been shown to be ineffective.
Correct answer is B. The rate of vaginal birth after Cesarean (VBAC) has decreased in recent
years due to studies that showed an increased risk of complications, especially uterine
rupture. This is one factor that has led to the increased Cesarean section rate. In addition,
although the rate of breech presentation is stable, there are significantly fewer obstetricians
who are willing to perform vaginal breech deliveries. Many obstetricians do not perform
instrumental vaginal deliveries, such as forceps and vacuum extractions, further contributing
to the rising rate. Gestational diabetes is a well-known pregnancy complication with clear
clinical guidelines.

A. The rate of breech presentations

has increased
B. Less women are having vaginal
births after Cesarean
C. Obstetricians' reluctance to
perform forceps delivery
D. Increased rate of fetal macrosomia
due to uncontrolled gestational
diabetes
E. Rate of twins has increased
20. A 33-year-old G2P1 woman at 29 Correct answer is A. Antibiotic therapy given to patients with preterm premature rupture of
weeks gestation presents with the membranes has been found to prolong the latency period by 5-7 days, as well as reduce
confirmed preterm premature the incidence of maternal amnionitis and neonatal sepsis. Corticosteroids (betamethasone)
rupture of membranes. She denies and tocolytics may also prolong the pregnancy for various lengths of time, but generally not
labor. She takes prenatal vitamins seven days.
and iron. She denies substance
abuse, smoking or alcohol use. Her
prior pregnancy was delivered
vaginally at 41 weeks after
spontaneous rupture of membranes.
Her blood pressure is 110/70; pulse
84; temperature 98.6F (37.0C).
Which of the following is the best
medication to delay the onset of
labor?
A. Antibiotics
B. Betamethasone
C. Calcium channel blocker
D. Beta mimetics
E. Magnesium sulfate
21. A 33-year-old G2P1 woman presents at 12
weeks gestation for routine prenatal visit. She
has had an uncomplicated prenatal course.
Doppler fetal heart tones are not heard and
the ultrasound today shows a crown rump
length of 8 mm with no cardiac activity and a
retroverted uterus. What is the next step in the
management of this patient?
Correct answer is D. This patient has a missed abortion and should be offered
uterine evacuation. Ultrasound criteria for a missed abortion are a CRL of > 7 mm
with no cardiac activity. Medical induction using misoprostol has been shown to be
efficacious and associated with less complications when compared to surgical
evacuation. Checking a serum progesterone and following serial Beta-hCG may be
indicated in confirming a viable pregnancy. Methotrexate is used in the treatment of
selected ectopic pregnancies and can be used to induce medical terminations of
pregnancies if the LMP was < six weeks ago.

A. Check a serum progesterone level

B. Obtain serial Beta-HCG levels every two
days
C. Repeat the ultrasound in seven days
D. Medical induction with misoprostol
E. Medical induction with methotrexate
22. A 34-year-old G1P0 woman is in a motor Correct answer is B. The risk of developing microcephaly and severe intellectual
vehicle accident. While in the emergency disability is greatest between eight and 15 weeks gestation. In 1990, the Committee
department, the doctors order multiple x-rays on Biological Effects reported that no risk of mental retardation (now referred to as
to evaluate her injuries. At what gestational intellectual disability) has been documented with doses even exceeding 50 rad at
age would the fetus be most susceptible to less than eight weeks or greater than 25 weeks gestation.
developing intellectual disability with
sufficient doses of radiation?

A. 0-7 weeks
B. 8-15 weeks
C. 16-25 weeks
D. 26-30 weeks
E. 31-35 weeks
23. A 35-year-old G3P3 woman comes to the Correct answer is B. Tubal ligation has not been shown to reduce the risk of breast,
office to discuss tubal ligation as she desires cervical, or endometrial cancers, nor is there a decrease in menstrual blood flow in
permanent sterilization. The non- women who have undergone a tubal ligation. There is a slight reduction in the risk
contraceptive health benefits of female of ovarian cancer, but the mechanism is not yet fully understood.
sterilization reduce the risk of which of the
following?

A. Breast cancer
B. Ovarian cancer
C. Endometrial cancer
D. Cervical cancer
E. Menorrhagia
24. A 36-year-old G1P0 Asian woman Correct answer is C. Assisted reproduction has led to an increase number of multiple
presents to the office accompanied by gestations. The rates of multiple births after IVF (in-vitro fertilization) vary according to
her 32-year-old husband. She is maternal age and the number of embryos transferred. Transfer of multiple embryos is more
thrilled that she is now pregnant with likely to result in multiple gestations in younger women than in older women. The frequency
twins after undergoing in vitro of multiple gestations increases with the use of ovulation inducing drugs. The risk is in the 5-
fertilization. She has a history of 6% range, but varies depending on the drug and dosage regimen used. Dizygous twinning
polycystic ovarian syndrome and results from the ovulation of multiple follicles and the rate of multiple gestation increases
thought she would not be able to have with advancing maternal age. Elevated follicle-stimulating hormone correlates with
a baby. Her husband has a twin dizygous multiple births. A higher number of prior pregnancies and previous history of
brother. Which of the following is the multiple births increases the chance of having a multiple gestation. These do not apply here
most likely cause of twins in this because the patient's obstetrical history does not support this. Dizygous twinning appears
patient? to have a genetic component and rates of dizygous twins vary according to ethnicity, but
A. Advanced maternal age are not related to paternal family history.
B. Ethnicity
C. Assisted reproductive technology
D. Nulliparity
E. Paternal family history
25. A 37-year-old G4P3 woman presents Correct answer is D. Prostaglandin F2-alpha should be administered intramuscularly. It
in labor at term. Her medical history could also be injected directly into the uterine muscle. Prostaglandin F2-alpha should not
and prenatal course are be administered IV, as it can lead to severe bronchoconstriction. Oxytocin is administered
uncomplicated. She delivers a 3500 as a short time, rapid infusion of a dilute solution (20-80 units in a liter) and not as an IV
gram infant spontaneously after bolus/push. Misoprostol (800 to 1000 mcg) can be administered orally or rectally and is not
oxytocin augmentation of labor. administered IV or IM.
Immediately postpartum, there is
excessive bleeding greater than 2000
cc. She has an IV in place. There are
no lacerations and the uterus is found
to be boggy. Which of the following is
the most appropriate next step in the
non-operative management of this
patient?
A. Intravenous misoprostol
B. Intramuscular misoprostol
C. Intravenous prostaglandin F2-alpha
D. Intramuscular prostaglandin F2-
alpha
E. Intravenous oxytocin push
26. A 38-year-old G2P0 woman at 28 weeks gestation has been
diagnosed with preterm labor and is currently stable on nifedipine.
Her cervical exam has remained unchanged at 2 cm dilated, 75%
effaced and -2 station. Her vital signs are stable and fetal heart
tracing is category I. You recommend treatment with
betamethasone (a steroid). Which of the following is associated
with betamethasone therapy in the newborn?
A. Enhancement of fetal growth
B. Increased risk of infection
C. Increased incidence of necrotizing enterocolitis
D. Increased incidence of intracerebral hemorrhage
E. Decreased incidence of intracerebral hemorrhage
27. A 40-year-old G1P0 woman at 22 weeks gestation presents to the
office with a complaint of pelvic pressure. She reports that she had
intercourse the night prior to presentation and noted some mucous
mixed with blood this morning. Her history is significant for type 1
diabetes and she is on an insulin pump. Her surgical history is
significant for a history of cone biopsy for treatment of abnormal
Pap smear three years ago. On examination, her BMI is 26. She is
noted to have a 2 cm dilated cervix with bulging membranes that
rupture upon placing the speculum. Fetal parts are noted in the
vagina. What is the most likely cause of this finding?
A. Uncontrolled diabetes
B. Cervical incompetence/insufficiency
C. Preterm labor
D. Advanced maternal age
E. Infection
28. A 48-year-old G2P2 woman comes to your office because she has
skipped her menstrual period for the past three months. She
denies any menopausal symptoms. Review of symptoms and
physical exam are unremarkable. What is the most likely diagnosis
in this patient?
A. Hypothyroidism
B. Early pregnancy
C. Perimenopause
D. Premature ovarian failure
E. Autoimmune disorder
29. A 49-year-old G1P1 woman comes to your office for menopause
counseling. She has been experiencing severe sleep disturbances
and night sweats for the past four months. She would like to begin
hormone therapy, but is concerned because she has elevated
cholesterol levels for which she takes medication. You explain to
her that hormone therapy has the following effect on a
lipid/cholesterol profile:
A. Both HDL and LDL levels increase
B. Both HDL and LDL levels decrease
C. HDL and LDL levels are unaffected
D. HDL levels increase and LDL levels are unaffected
E. HDL levels increase and LDL levels decrease
Treatment with betamethasone from 24 to 34 weeks gestation
has been shown to increase pulmonary maturity and reduce
the incidence and severity of RDS (respiratory distress
syndrome) in the newborn. It is also associated with
decreased intracerebral hemorrhage and necrotizing
enterocolitis in the newborn. It has not been associated with
increased infection or enhanced growth.
B. The most likely cause of painless cervical dilation which
leads to pelvic pressure, bulging membranes and fetal loss is
cervical incompetence or insufficiency. This patient has a
history of cone biopsy which can lead to cervical
incompetence. Preterm labor by definition does not occur
until 24 weeks gestation. Although uncontrolled diabetes can
lead to fetal malformations and early miscarriage, it is not
typically a cause of fetal loss in the second trimester.
Advanced maternal age is associated with an increased risk of
stillbirth, preeclampsia, gestational diabetes and intrauterine
growth restriction.
Although there has been a decline in the average age of
menarche with the improvement in health and living
conditions, the average age of menopause has remained
stable. The Massachusetts Women's Health Study reports that
the average age of menopause is 51.3. This patient is most
likely perimenopausal and will probably have more menstrual
periods in the future. Although it is important to consider
pregnancy and hypothyroidism, this patient's presentation is
most consistent with perimenopause. Premature ovarian
failure occurs before age 35.
Recent data have confirmed the overall positive effects of
hormone therapy on serum lipid profiles. The most important
lipid effects of postmenopausal hormone treatment are the
reduction in LDL cholesterol and the increase in HDL
cholesterol. Estrogen increases triglycerides and increases
LDL catabolism, as well as lipoprotein receptor numbers and
activity, therefore causing decreased LDL levels. Hormones
inhibit hepatic lipase activity, which prevents conversion of
HDL2 to HDL3, thus increasing HDL levels. Hormone therapy
is not currently recommended for the primary prevention of
heart disease.
30. A 49-year-old G2P2 woman status post hysterectomy at age 45 for
fibroids presents to your office complaining of severe vasomotor
symptoms for three months. Hot flashes are affecting her quality of
life and she would like to discuss options for treatment. What
treatment option for hot flashes associated with menopause do you
recommend as the most effective?
A. Lifestyle modifications such as dressing in layers
B. Estrogen
C. Selective estrogen receptor modulator (SERMs)
D. Selective serotonin reuptake inhibitors (SSRIs)
E. Treatment with phytoestrogen (soy)
31. A 51-year-old G1P1 woman presents for annual examination. She
notes vaginal dryness, some hot flashes, and fatigue. She reports that
her last menstrual period was 14 months ago. She and her husband
use lubrication for intercourse, and she denies any significant pain.
Her past medical history is significant for hypertension, which she
controls with diet and regular exercise. She is concerned that she
should begin hormone replacement, because her mother started HRT
around the same age. Which of the following is the most appropriate
next step in her management?
A. Expectant management
B. FSH level
C. LH level
D. Estrogen level
E. Initiate combination HRT
32. A 53-year-old G2P2 woman comes to your office complaining of six
months of worsening hot flashes, vaginal dryness, night sweats, and
sleep disturbances. Her last normal menstrual period was six months
ago and she has been experiencing intermittent small amounts of
vaginal bleeding. Her medical history is significant for hypertension,
which is well-controlled by a calcium-channel blocker, type 2
diabetes, for which she takes metformin, and hyperthyroidism, for
which she takes propylthiouracil. The patient is 5 feet 7 inches tall
and weighs 140 pounds. Blood pressure is 120/70. Physical
examination is unremarkable. Which of the following medical
conditions in this patient is a contraindication to treatment of
menopausal symptoms with hormone therapy?
A. Vaginal bleeding
B. Hypertension
C. Diabetes
D. Osteoporosis
E. Hyperthyroidism
Except for estrogen receptor modulator therapy, all of the
above treatment options will improve hot flash symptoms.
Treatment with estrogen is most effective, and the current
recommendation is for the lowest dose for the shortest
duration of time. Hot flashes will resolve completely in 90%
of patients receiving this therapy. Raloxifene, a selective
estrogen receptor modulator, may actually cause hot
flashes to worsen in a patient who has not stopped having
these symptoms completely. SSRI antidepressants, some
anti-seizure medications and alternative treatments, such as
soy products and herbs, have not been shown to be as
effective as estrogen.
Expectant management is reasonable in this patient, as she
notes minimal menopausal symptoms. Her vaginal dryness
is not interfering with her ability to enjoy intercourse, and
she has only occasional hot flashes. An FSH level is not
indicated as by definition she is menopausal given
amenorrhea for greater than 12 months. Estrogen and LH
levels are not indicated in the diagnosis of menopause.
While HRT is appropriate for patients with significant
menopausal symptoms, and should be used at the lowest
effective dose for the shortest amount of time, this patient
at this time is not experiencing significant symptoms and
therefore HRT should not be initiated at this time.
The principal symptom of endometrial cancer is abnormal
vaginal bleeding. Although the patient's worsening
symptoms make treatment an important consideration, the
specific organic cause(s) of abnormal bleeding must be
ruled out prior to initiating therapy. A tissue diagnosis
consistent with normal endometrium or a pelvic ultrasound
with an endometrial stripe of <4 mm ought to be
documented. In addition, risks and benefits of hormone
replacement therapy must be discussed with this patient at
length prior to beginning treatment.
33. A 54-year-old G2P2 woman presents to your office for
a health maintenance examination. Her last menstrual
period was eight months ago. She complains of severe
vasomotor symptoms, vaginal dryness, and
dyspareunia, and desires treatment for her symptoms.
She has otherwise been in good health and has no
significant past medical or surgical history. Her family
history is significant for a mother who has severe
osteoporosis at the age of 75, a grandmother who died
of breast cancer at the age of 79, and a father who died
at age 77 from a myocardial infarction. She denies
smoking, alcohol or drug use. On physical exam her BP
is 130/78, pulse is 84, and BMI is 26. The remainder of
her exam is within normal limits except for severe
vaginal atrophy noted on the pelvic examination. The
best recommendation for this patient would include
which of the following?
A. Lowest effective dose of combination hormone
replacement therapy for the shortest duration possible
B. Long term hormone replacement therapy to treat her
vasomotor symptoms and prevention of osteoporosis
C. Testosterone cream
D. Progesterone cream
E. Biosphophonates
34. A 54-year-old G4P4 woman who has been menopausal
for four years recently underwent a total vaginal
hysterectomy and bilateral salpingo-oophorectomy for
vaginal prolapse. She comes in for a postoperative
check up and complains of hot flashes and wonders
why she is experiencing menopause again. Which of the
following most likely explains why she is experiencing
these symptoms?
A. Increased postoperative liver metabolism
B. Decreased adrenal estrogen production
C. Removal of an occult estrogen-producing tumor
D. Decreased circulating androgens
E. Cessation of ovarian estrogen production
The American College of Obstetricians and Gynecologists (ACOG)
recommendations on hormone replacement therapy considers hormone
replacement therapy (HRT) the most effective treatment for severe
menopausal symptoms that include hot flashes, night sweats and vaginal
dryness. The physician should counsel the woman about the risks and
benefits before initiating treatment. ACOG recommends "the smallest
effective dose for the shortest possible time and annual reviews of the
decision to take hormones." HRT should not be used to prevent
cardiovascular disease due to the slight increase in risk of breast cancer,
myocardial infarction, cerebrovascular accident, and thromoboembolic
events. A woman with an intact uterus should not use estrogen-only
therapy because of the increased risk of endometrial cancer. In addition
to the same risks as FDA approved treatments, bioidentical hormones
such as testosterone and progesterone cream may have additional
associated risks. While her family history is significant for one second
degree relative with breast cancer, this is not an absolute
contraindication for short-term HRT.
Estrogen production by the ovaries does not continue beyond
menopause. However, estrogen levels in postmenopausal women can be
significant due to the extraglandular conversion of androstenedione and
testosterone to estrogen. This conversion occurs in peripheral fat cells
and, thus, body weight has been directly correlated with circulating
levels of estrone and estradiol. Since menopausal ovaries are known to
continue production of androgens, surgical removal of postmenopausal
ovaries may result in the resurgence of menopausal symptoms from the
abrupt drop in circulating androgens.
35. A 58-year-old G3P1 woman presents to your office for her a
health maintenance examination. She became menopausal
at age 54. Her past medical history is significant for angina.
She experienced a hip fracture 14 months ago when she
tripped and fell while running after her grandson. She has
not had any surgeries. She takes no medications and has no
known drug allergies. She smokes 10 cigarettes a day and
drinks a glass of red wine at dinner. Her father was
diagnosed with colon cancer at the age of 72. Physical exam
revealed a blood pressure of 120/68, pulse of 64, and BMI of
22. Her heart, lung, breast and abdominal exams were
normal. Pelvic exam was consistent with vaginal atrophy and
a small uterus. There was no adnexal tenderness and no
masses were palpated. In addition to obtaining a bone
mineral density scan, what is the next step in the
management plan for this patient?
A. Repeat bone mineral density in one year
B. Repeat bone mineral density at age 65
C. Begin hormone replacement therapy
D. Begin treatment with bisphosphonates
E. Test for the presence of biochemical bone markers in the
blood
36. A 58-year-old G3P3 woman has been postmenopausal for
five years and is concerned about osteoporosis. She has
declined hormone therapy in the past. Her mother has a
history of a hip fracture at age 82. A physical exam is
unremarkable. In addition to weight bearing exercise and
vitamin D supplementation, what optimal daily calcium
intake should she take?
A. None
B. 400 mg
C. 800 mg
D. 1200 mg
E. 1600 mg
37. A 58-year-old G3P3 woman who has been menopausal since
age 50 comes to you for a health maintenance examination.
She is in good health, eats a balanced diet, exercises
regularly, and has an unremarkable physical exam. Her bone
mineral density as determined by central dual energy X-ray
absorptiometry is -1.7. She wants to discuss treatment for her
osteopenia. What is the next step in the management of this
patient?
A. Evaluate her risk factors for fracture
B. Determine her frequency of exercise
C. Assess her exogenous dietary intake of estrogen
D. Assess her exogenous dietary intake of progesterone
E. Repeat DEXA scan in one year
This patient has many of the major risk factors for osteoporosis
including history of fracture as an adult, low body weight and being
a current smoker. Patients who already have had an osteoporotic
fracture may be treated on this basis alone. Prior to beginning
treatment with bisphosphonates, a bone mineral density (BMD)
should be documented and repeated at two-year intervals to
monitor treatment. DEXA is the test of choice for measuring BMD. A
nuclear medicine bone scan may be useful to rule out a pathologic
fracture from metastatic disease. General recommendations for the
prevention of osteoporosis include eating a balanced diet that
includes adequate intake of calcium and vitamin D, regular physical
activity, avoidance of heavy alcohol consumption, and smoking
cessation. Bone markers are used in research but are not yet a
reliable predictor of BMD. Hormone replacement therapy is not
recommended long term for disease prevention especially in
patients with cardiovascular disease.
Calcium absorption decreases with age because of a decrease in
biologically active vitamin D. A positive calcium balance is necessary
to prevent osteoporosis. Calcium supplementation reduces bone
loss and decreases fractures in individuals with low dietary intakes. In
order to remain in zero calcium balance, postmenopausal women
require a total of 1200 mg of elemental calcium per day.
The World Health Organization (WHO) defines osteopenia (low
bone mass) as -1 to -2.5. The American College of Obstetricians and
Gynecologists (ACOG) Committee Opinion recommends that
physicians interpret T scores between 1.0 and 2.5 in combination
with the patient's risk factors for fracture. The authors state:
"Clinicians must be careful because the diagnosis of osteopenia
often is interpreted as indicating a pathologic skeletal condition or
significant bone loss, neither of which is necessarily true. Until better
models of absolute fracture risk exist, postmenopausal women in
their 50s with T scores in the osteopenia range and without risk
factors may well benefit from counseling on calcium and vitamin D
intake and risk factor reduction to delay initiation of pharmacologic
intervention." Some of the risk factors for fracture include prior
fracture, family history of osteoporosis, race, dementia, history of
falls, poor nutrition, smoking, low body mass index, estrogen
deficiency, alcoholism, and insufficient physical activity.
38. Factors Prematurity, multiple gestation, genetic disorders, polyhydramnios, hydrocephaly, anencephaly, placenta previa,
associated w/ uterine anomalies and uterine fibroids are all associated with breech presentation.
breech
presentation
39. How calcium 1,200 mg
should be given
to a
postmenopausal
woman?
40. Infertility facts After one month, 20% of couples will conceive; after three months, 50%; after six months, 75%; and after 12
months, 90% will conceive. Primary infertility is defined as the inability to conceive for one year without
contraception. The patient is young and healthy with no obvious reasons for infertility, so at this point reassurance
and observation is the proper management.
41. Obstetric The FVL mutation is associated with obstetric complications including stillbirth, preeclampsia, placental abruption
complications: and IUGR. Fetuses with Trisomy 18 are likely to have congenital anomalies that are detectable on prenatal
FVL mutation, ultrasound. Over 90% of cases of trisomy 21 and 18 may be detected with the quad screen. A congenital
Trisomy 18,21, parvovirus infection associated with a fetal demise would likely cause hydrops in the fetus which would be
diabetes, and identified on ultrasound. Although poorly controlled diabetes mellitus are associated with fetal demise, they are
parvo. not the most likely etiologies in this patient whose presentation is classic for the FVL mutation.
42. The operative Correct answer is D. Correcting coagulation deficiencies requires replacing all necessary blood components.
team decides to Fresh frozen plasma contains fibrinogen, as well as clotting factors V and VIII. Cryoprecipitate contains fibrinogen,
give her fresh factor VIII and von Willebrand's factor. Neither of these preparations contains red blood cells or platelets, which
frozen plasma must be given separately.
(FFP) to replace
which of the
following
components?
A. Platelets
B. Von
Willebrand's
factor
C. Red blood
cells
D. Fibrinogen
E. Factor X
43. Outline some Other risk factors for preeclampsia include a previous history of the disease, chronic hypertension, multifetal
risk factors for pregnancy and molar pregnancy. In addition, patients at extremes of maternal age or with diabetes, chronic renal
pre-eclampsia. disease, antiphospholipid antibody syndrome, vascular or connective tissue disease or triploidy are at increased
risk for developing preeclampsia
44. read. Uncontrolled glucose is associated with adverse fetal outcome. A patient with type 1 diabetes is at risk for many
pregnancy complications, including fetal death and fetal macrosomia, although fetal growth restriction may also
occur. Diabetics also have increased risk for polyhydramnios, congenital malformations (cardiovascular, neural
tube defects, and caudal regression syndrome), preterm birth, and hypertensive complications. The anemia most
often seen in pregnancy is mild and would not be the most likely cause. It is unlikely that she has an abruption
causing the anemia, but this should be considered. Hypothyroidism is usually associated with menstrual
irregularities and infertility, and is a less likely cause. Rh sensitization is unlikely since this is her first pregnancy and
she did not have any bleeding or procedures during the pregnancy.
45. Read card. Fetal hydrops is easily diagnosed on ultrasound. It develops in the presence of decreased hepatic protein
production. It is defined as a collection of fluid in two or more body cavities, such as ascites, pericardial and/or
pleural fluid and scalp edema. On occasion, when extramedullary hematopoiesis is extensive, there will be
evidence of hepatosplenomegaly. Placentomegaly (placental edema) and polyhydramnios are also seen on
ultrasound. Meconium, fetal bladder obstruction, oligohydramnios and placenta previa do not fit the clinical
scenario.
46. A therapeutic 4-7 mEq/L.
magnesium level is
between _________
47. Uncontrolled diabetes Uncontrolled diabetes during organogenesis is associated with a high rate of birth defects. The most
during pregnancy common sites affected are the spine and the heart of the fetus, although all birth defects are increased.
Fetuses in utero exposed to high levels of glucose transplacentally have increased growth and polyuria
resulting in an increase in the amniotic fluid. While some viral infections are also associated with
placentomegaly and polyhydramnios, the fetus will have normal or decreased growth depending on the
timing of the infection. Severe hypertension and active APAS is often associated with oligohydramnios and
intrauterine growth restriction. The risk of miscarriage is increased if hypothyroidism goes untreated.
48. What happens at a Loss of deep tendon reflexes
magnesium level of 7-
10 mEq/L
49. What happens at a respiratory depression
magnesium level of 11
mEq/L
50. What happens at a cardiac arrest
magnesium level of 15
mEq/L. What is a side Pulmonary edema can occur with magnesium therapy, but is not related to toxicity from the drug.
effect of magnesium
therapy associated w/
the lungs? (hint: not
related to toxicity from
the drug)
51. What is the most The routine dose of RhoGAM neutralizes 30 cc of fetal blood. The Kleihauer-Betke test is an accurate and
appropriate method to sensitive acid elution test. It has great value in determining the incidence and size of fetal transplacental
determine the correct hemorrhage. In this test, using acid elution, the mother's red blood cells become very pale, while fetal
RhoGAM dose to give cells, which contain a different form of hemoglobin, remain stained. Simple comparative counts allow an
to the patient? estimate of whether a significant fetal maternal transfusion has occurred.

A. Determine delta OD
450 (optical density)
B. Measure fetal
hemoglobin levels
C. Perform a Kleihauer-
Betke test
D. Measure maternal
hemoglobin levels
E. Administer routine
dose of RhoGAM at
time of incident
 Unit 2: Obstetrics A - Normal Obstetrics
Study online at quizlet.com/_2iibny
1. A 16-year-old G1P0 woman at 39 weeks gestation presents to labor and
delivery reporting a gush of blood-tinged fluid approximately five hours
ago and the onset of uterine contractions shortly thereafter. She reports
contractions have become stronger and closer together over the past
hour. The fetal heart rate is 140 to 150 with accelerations and no
decelerations. Uterine contractions are recorded every 2-3 minutes. A
pelvic exam reveals that the cervix is 4 cm dilated and 100 percent
effaced. Fetal station is 0. After walking around for 30 minutes the patient
is put back in bed after complaining of further discomfort. She requests
an epidural. However, obtaining the fetal heart rate externally has
become difficult because the patient cannot lie still. What is the most
appropriate next step in the management of this patient?
A. Place the epidural
B. Apply a fetal scalp electrode
C. Perform a fetal ultrasound to assess the fetal heart rate
D. Place an intrauterine pressure catheter (IUPC)
E. Recommend a Cesarean delivery
2. A 17-year-old G1P0 woman at 32 weeks gestation complains of right flank
pain that is "colicky" in nature and has been present for two weeks. She
denies fever, dysuria and hematuria. Physical examination is notable for
moderate right costovertebral angle tenderness. White blood cell count
is 8,800/mL and urine analysis is negative. A renal ultrasound reveals no
signs of urinary calculi, but there is moderate (15 mm) right
hydronephrosis. Which of the following is the most likely cause of these
findings?
A. Smooth muscle relaxation due to declining levels of progesterone
B. Smooth muscle relaxation due to increasing levels of estrogen
C. Compression by the uterus and right ovarian vein
D. Elevation of the bladder in the second trimester
E. Iliac artery compression of the ureter
3. A 17-year-old G1P1 female delivered a term infant two days ago. She is
not interested in breastfeeding and she asks for something to suppress
lactation. Which of the following is the safest method of lactation
suppression in this patient?
A. Bromocriptine
B. Breast binding, ice packs and analgesics
C. Medroxyprogesterone acetate
D. Oral contraceptives
E. Manual milk expression
B. If the fetal heart rate cannot be confirmed using
external methods, then the most reliable way to
document fetal well-being is to apply a fetal scalp
electrode. Putting in an epidural without confirming fetal
status might be dangerous. Although ultrasound will
provide information regarding the fetal heart rate, it is
not practical to use this to monitor the fetus
continuously while the epidural is placed. An intrauterine
pressure catheter will provide information about the
strength and frequency of the patient's contractions, but
will not provide information regarding the fetal status.
Closer fetal monitoring via a fetal scalp electrode
should be performed.
C. Some degree of dilation in the ureters and renal
pelvis occurs in the majority of pregnant women. The
dilation is unequal (R > L) due to cushioning provided by
the sigmoid colon to the left ureter and from greater
compression of the right ureter due to dextrorotation of
the uterus. The right ovarian vein complex, which is
remarkably dilated during pregnancy, lies obliquely over
the right ureter and may contribute significantly to right
ureteral dilatation. High levels of progesterone likely
have some effect but estrogen has no effect on the
smooth muscle of the ureter
B. Hormonal interventions for preventing lactation
appear to predispose to thromboembolic events, as
well as a significant risk of rebound engorgement.
Bromocriptine, in particular, is associated with
hypertension, stroke and seizures. The safest method to
suppress lactation is breast binding, ice packs and
analgesics. The patient should avoid breast stimulation
or other means of milk expression, so that the natural
inhibition of prolactin secretion will result in breast
involution.
4. An 18-year-old G1P0 Asian woman is seen in the clinic for a routine prenatal visit
at 28 weeks gestation. Her prenatal course has been unremarkable but she has
been reporting increased fatigue. She has not been taking prenatal vitamins. Her
pre-pregnancy weight was 120 pounds. Initial hemoglobin at the first visit at
eight weeks gestation was 12.3 g/dL. Current weight is 138 pounds. After
performing a screening complete blood count (CBC), the results are notable for
a white blood cell count 9,700/mL; hemoglobin 10.6 g/dL; mean corpuscular
volume 88.2 fL (80.8 - 96.4); and platelet count 215,000/mcL. The patient denies
vaginal or rectal bleeding. Which of the following is the best explanation for this
patient's anemia?
A. Folate deficiency
B. Relative hemodilution of pregnancy
C. Iron deficiency
D. Beta thalassemia trait
E. Alpha thalassemia trait
5. An 18-year-old G1P0 woman at 12 weeks gestation reports nausea, vomiting,
scant vaginal bleeding and a "racing heart." These symptoms have been present
on and off for the past four weeks. The patient has no significant past medical,
surgical or family history. Vital signs are: temperature 98.6F (37C); heart rate
120 beats/minute; blood pressure 128/78. On physical examination: uterine
fundus is 4 cm below the umbilicus; no fetal heart tones obtained by fetal
Doppler device; cervix is 1 cm dilated with pinkish/purple "fleshy" tissue
protruding through the os. Labs show: hemoglobin 8.2 gm/dL, quantitative Beta-
hCG 1.0 Million IU/mL; thyroid-stimulating hormone (TSH) undetectable; free T4
3.2 (normal 0.7 - 2.5). An ultrasound reveals heterogeneous cystic tissue in the
uterus (snowstorm pattern). Which of the following is the most appropriate next
step in the management of this patient?
A. Repeat quantitative Beta-hCG
B. Repeat transvaginal ultrasound
C. PET scan
D. Chest x-ray
E. CBC
6. An 18-year-old G1P0 woman presents for prenatal care at 6 weeks gestation. Her
medical, surgical, gynecologic, social and family history are unremarkable. Her
dietary history includes high carbohydrate intake with no fresh vegetables. Her
physical examination is within normal limits except that she is pale and has a BMI
of 42. Nutritional counseling should include the following:
A. 25-30 grams of protein in her diet every day
B. A strict diet to maintain her current weight
C. Folic acid supplementation
D. Intake of 1200 calories a day
E. Initiation of a vigorous weight loss exercise program
B. There is normally a 36% increase in maternal
blood volume; the maximum is reached around
34 weeks. The plasma volume increases 47% and
the RBC mass increases only 17%. This relative
dilutional effect lowers the hemoglobin, but
causes no change in the MCV. Folate deficiency
results in a macrocytic anemia. Iron deficiency
and thalassemias are associated with microcytic
anemia.
D. This patient's presentation is classic for a
molar pregnancy. Beta-hCG levels in normal
pregnancy do not reach one million. A chest x-
ray would be the most appropriate step, as the
lungs are the most common site of metastatic
disease in patients with gestational trophoblastic
disease. Though a repeat quantitative Beta-hCG
will be required on a weekly basis, an immediate
post-operative value will be of little clinical
utility. A PET scan is not indicated and the
patient already had a CBC done.
C. There should be folic acid supplementation,
as well as evaluation for deficiencies in her iron,
protein and other nutrient stores. In general, a
patient needs approximately 70 grams of protein
a day, along with her other nutrients. It would be
prudent to caution her that, though aerobic
exercise is recommended and would be a
benefit to her, it is not advisable to initiate a
vigorous program in a woman who has not been
routinely working out. Women should gain
weight during their pregnancy, and 1200 calories
a day is not sufficient for a pregnant woman.
7. A 19-year-old G1P0 woman at 39 weeks gestation presents in labor.
She denies ruptured membranes. Her prenatal course was
uncomplicated and ultrasound at 18 weeks revealed no fetal
abnormalities. Her vital signs are: blood pressure 120/70; pulse 72;
temperature 101.0 F (38.3 C); fundal height 36 cm; and estimated
fetal weight of 2900 gm. Cervix is dilated to 4 cm, 100% effaced
and at +1 station. She receives 10 mg of morphine intramuscularly
for pain and soon after has spontaneous rupture of the
membranes. Light meconium-stained fluid was noted and, five
minutes later, the fetal heart rate tracing revealed variable
decelerations with good variability. What is the most likely cause
for the variable decelerations?
A. Umbilical cord compression
B. Meconium
C. Maternal fever
D. Uteroplacental insufficiency
E. Umbilical cord prolapse
8. A 19-year-old G1P0 woman at 41-weeks gestation with two prior
prenatal visits at 35-weeks and 40-weeks, presents in active labor.
Review of available maternal labs shows: blood type O+; RPR non-
reactive; HBsAg negative; and HIV negative. She delivers a small
female infant who cries spontaneously. On examination, you find
the infant has a slightly flattened nasal bridge. Her ears are small
and slightly rotated. What is the most appropriate next step in the
management of this patient?
A. Tell the mother the infant will be fine
B. Tell the mother that her newborn has Down syndrome
C. Question the patient why an amniocentesis was not performed
D. Further examine the infant for wide-spaced nipples and
lymphedema
E. Further examine the infant for sandal gap toes and hypotonia
9. A 19-year-old G1P0 woman presents at 41 weeks gestation with a
fever, spontaneous ruptured membranes and no contractions. Her
temperature is 102.6 F (39.2 C); pulse 126. Ultrasound reveals a
singleton with decreased amniotic fluid and placenta partially
covering the os. The cervix appears long and closed. Which of the
following is an indication for Cesarean delivery in this patient?
A. Chorioamnionitis
B. Unfavorable cervix
C. Oligohydramnios
D. Placenta covering the cervical os
E. Spontaneous ruptured membranes not in labor
A. Variable decelerations are typically caused by cord
compression and are the most common decelerations seen in
labor. Placental insufficiency is usually associated with late
decelerations. Head compression typically causes early
decelerations. Oligohydramnios can increase a patient's risk of
having umbilical cord compression; however, it does not
directly cause variable decelerations. Umbilical cord prolapse
occurs in 0.2 to 0.6% of births. Sustained fetal bradycardia is
usually observed.
E. A flattened nasal bridge, small size and small rotated, cup-
shaped ears may be associated with Down syndrome and
should prompt a survey looking specifically for other features
seen with Down syndrome that include sandal gap toes,
hypotonia, a protruding tongue, short broad hands, Simian
creases, epicanthic folds, and oblique palpebral fissures. The
initial physical findings may be a variant of normal, therefore,
you should not share any concerns with the mother until you
perform a detailed physical examination. Wide-spaced nipples
and lymphedema are associated with Turner syndrome. It is not
standard of care to offer amniocentesis to a 19-year-old, unless
she has specific risk factors.
D. Cesarean delivery is indicated in this patient because of a
placenta previa (placenta covering the internal os). A vaginal
delivery is contraindicated in patients with a placenta previa.
Post-term pregnancies, chorioamnionitis, oligohydramnios, and
term premature rupture of membranes are all acceptable
indications for induction of labor and delivery if the patient is a
good candidate for initiation of labor. An unfavorable cervix is
not a contraindication for a vaginal delivery.
10. A 20-year-old G1P0 woman at 18 weeks gestation with a
history of epilepsy has conceived while taking valproic acid.
She is scheduled for an ultrasound. What is the most common
anomaly associated with prenatal exposure to valproic acid?
A. Cardiac defects
B. Caudal regression syndrome
C. Neural tube defects
D. Cleft lip and palate
E. Holoprosencephaly
11. A 21-year-old G1P0 woman delivered a 4000 gram infant by a
low-forceps delivery after a protracted labor course that
included a three-hour second stage. Her prenatal course was
notable for development of anemia, poor weight gain and
maternal obesity. Following the delivery, the patient was
noted to have a vaginal sulcus laceration and a third-degree
perineal laceration, which required extensive repair. Her
hematocrit was noted to be 30% on postpartum day one.
Which of the following factors places this patient at greatest
risk for developing a puerperal infection?
A. Third-degree perineal laceration
B. Poor nutrition
C. Obesity
D. Anemia
E. Protracted labor
12. A 21-year-old G1P1 woman presents to the office with
amenorrhea since the birth of her one-year-old daughter.
She reports extreme fatigue, forgetfulness, and depression.
She was unable to breastfeed because her milk never came
in. She notes hair loss including under her arms and in her
pubic area. Her delivery was complicated by a postpartum
hemorrhage, hypovolemic shock, requiring aggressive
resuscitation. She is afebrile. Vital signs are: blood pressure
90/50; pulse 84. The patient appears tired. Her exam is
normal but she is noted to have dry skin. A urine pregnancy
test is negative. Which of the following is the most likely
diagnosis in this patient?
A. Hyperprolactinemia
B. Hyperthyroidism
C. Sheehan Syndrome
D. Asherman Syndrome
E. Major depressive disorder
C. Valproic acid use during pregnancy is associated with a 1 to 2%
incidence of neural tube defects, specifically lumbar
meningomyelocele. Fetal ultrasound examination at approximately
16 to 18 weeks gestation is recommended to detect neural tube
defects. Other malformations have been reported in the offspring of
women being treated with valproic acid and a fetal valproate
syndrome has been described which includes spina bifida, cardiac
defects, facial clefts, hypospadius, craniosynostosis, and limb
defects, particularly radial aplasia. Case reports have associated
prenatal exposure to valproic acid with omphalocele and lung
hypoplasia. Caudal regression syndrome is a rare syndrome
observed in offspring of poorly controlled diabetics.
E.
Endometritis in the postpartum period is most closely related to the
mode of delivery. Endometritis can be found in less than 3% of
vaginal births and this is contrasted by a 5-10 times higher incidence
after Cesarean deliveries. Factors related to increased rates of
infection with a vaginal birth include prolonged labor, prolonged
rupture of membranes, multiple vaginal examinations, internal fetal
monitoring, removal of the placenta manually and low
socioeconomic status.
C. Sheehan Syndrome is a rare occurrence. When a patient
experiences a significant blood loss, this can result in anterior
pituitary necrosis, which may lead to loss of gonadotropin, thyroid-
stimulating hormone (TSH) and adrenocorticotropic hormone
(ACTH) production, as they are all produced by the anterior
pituitary. Signs and symptoms of Sheehan syndrome may include
slow mental function, weight gain, fatigue, difficulty staying warm, no
milk production, hypotension and amenorrhea. Sheehan's syndrome
frequently goes unnoticed for many years after the inciting delivery.
Treatment includes estrogen and progesterone replacement and
supplementation with thyroid and adrenal hormones.
13. A 22-year-old G1P0 woman at 38 weeks
gestation has been pushing for four hours.
You recommend an operative vaginal
delivery. In obtaining informed consent,
which of the following is less likely to
occur during a vacuum delivery vs.
forceps assisted delivery?
A. Maternal lacerations
B. Fetal cephalohematoma
C. Neonatal lateral rectus paralysis
D. Neonatal hyperbilirubinemia
E. Neonatal retinal hemorrhage
14. A 22-year-old G1P0 woman at 38 weeks
gestation presents in labor. Her prenatal
course and past history are
uncomplicated. She is having regular
contractions and, on examination, the
cervix is 5 cm, 100% effaced and fetal head
at +1 station. The fetal heart rate tracing is
shown below. What is the most likely
interpretation? Trough of fetal heart rate
prior to peak of CTX
A. Normal reassuring
B. Bradycardia
C. Early deceleration
D. Variable decelerations
E. Late decelerations
15. A 22-year-old G1P0 woman currently at
eight weeks gestation is noted to have a
missed abortion on ultrasound, along with
a retroverted uterus. She elects to
undergo suction dilation and curettage.
During the procedure, "fatty appearing
tissue" is noted to be coming through the
curette. What is the next best step in the
management of this patient?
A. Newer forms of vacuum extractors cause less maternal discomfort as they are
applied to the vertex of the fetal head and do not take up additional space in the
maternal pelvis. If properly applied, this leads to a decreased rate of maternal
lacerations. Fetal and neonatal complications related to vacuum use include lacerations
at the edges of the vacuum cup, particularly if torsion is applied. Torsion may also lead
to separation of the fetal scalp from the underlying structures can cause a
cephalohematoma and places the fetus at risk of jaundice. Transient neonatal lateral
rectus paralysis has been found to occur more frequently in vacuum-assisted deliveries,
but, because the paralysis resolves spontaneously, it is unlikely to be of clinical
importance.
C. Early decelerations are thought to represent the fetal response to head compression
during the contraction and the fetal heart rate inversely mirrors the changes noted
during the contraction. Variable contractions are thought to be due to cord
compression and can occur at any time in relation to a contraction. Generally, they
have an abrupt onset and return of the fetal heart rate deceleration to the baseline
heart rate. Late decelerations are thought to represent uteroplacental insufficiency. The
deceleration of the fetal heart rate occurs at or after the peak of the uterine
contraction and returns to baseline after complication of the contraction. Bradycardia is
defined as fetal heart rate less than 110 beats per minute.
D. The tissue is consistent with omental tissue and may include segments of bowel. The
suction should be turned off and the tissue gently removed from the curette.
Laparoscopy will allow closer examination and should bowel appear to be involved,
the surgeon should consider laparotomy for closer evaluation of the bowel for
damage. The other options would place the patient at increased risk of complications
and delay diagnosis.

A. Continuing with the suction curettage

B. Remove the tissue from the curette and
replace it into the uterus
C. Cut the tissue off at the cervical os
D. Proceed with laparoscopy
E. Stop the procedure and observe her the
hospital for 48-hours
16. A 22-year-old G1P0 woman, who is at 38
weeks gestation with an estimated fetal
weight of 2500 g, presents in active
labor. She is completely dilated and
effaced. The fetus is at +4 station and left
occiput anterior with no molding. She has
an epidural and has been pushing
effectively for three hours. She is
exhausted. What is the next step in
management?
D. This patient meets all the requirements for an operative vaginal delivery. Forceps
application requires complete cervical dilation, head engagement, vertex presentation,
clinical assessment of fetal size and maternal pelvis, known position of the fetal head,
adequate maternal pain control and rupture of membranes. Strict adherence to the
guidelines suggested by the American College of Obstetricians and Gynecologists
(ACOG) for low forceps delivery does not increase the fetal or maternal risks when
performed by an experienced operator.

A. Allow to continue pushing until the

baby delivers
B. Start Oxytocin to strengthen
contractions
C. Discontinue the epidural
D. Forceps-assisted vaginal delivery
E. Cesarean section
17. A 22-year-old G2P1 woman comes to
your clinic today with her three-month-
old daughter. She was breastfeeding
without problems until about two weeks
ago, when she began to experience sore
nipples. The nipples are very sensitive
and there is a burning pain in the breasts,
which is worse when feeding. The tips of
the nipples are pink and shiny with
peeling at the periphery. Which of the
following organism is the most likely
cause of these findings?
E. This presentation is classic for candidiasis and should prompt an inspection of the
baby's oral cavity. Candida of the nipple is associated with severe discomfort and pain.
All the other above organisms are associated with classic mastitis and do not usually
cause intense nipple pain. Localized candida of the nipple may be treated with an
antifungal, topical medication such as clotrimazole or miconazole cream. The treatment
plan may include a topical antibiotic ointment because nipple fissures can concurrently
present with candida of the nipples, and S. aureus is significantly associated with nipple
fissures. Either a triple antibiotic ointment or mupirocin can be prescribed. A topical
steroid cream can be used to facilitate healing for cases in which the nipples that are
very red and inflamed. Every treatment regimen must include the simultaneous treatment
of the mother and baby. Oral nystatin is the most common treatment for the baby,
followed by oral fluconazole.

A. Group A streptrococcocus
B. Group B streptrococcocus
C. Staphylococcus aureus
D. Staphylococcus epidermidis
E. Candida
18. A 23-year-old G1P0 at 39 weeks D. Infants born to diabetic mothers are at increased risk for developing hypoglycemia,
gestation presents in spontaneous labor. polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress.
Pregnancy was complicated by Thrombocytopenia is not a risk.
gestational diabetes. She delivers a 4200
gram infant with ruddy color and
jitteriness. The infant is at immediate risk
for which of the following conditions?

A. Hyperglycemia
B. Anemia
C. Thrombocytopenia
D. Polycythemia
E. Hypercalcemia
19. A 23-year-old G1P0 woman at 38 weeks gestation,
with an uncomplicated pregnancy, presents to
labor and delivery with the complaint of lower
abdominal pain and mild nausea for one day. Fetal
kick counts are appropriate. Her review of
symptoms is otherwise negative. Vital signs are:
temperature 98.6F (37.0C); blood pressure 100/60;
pulse 79; respiratory rate 14; fetal heart rate 140s,
reactive, with no decelerations; tocometer shows
irregular contractions every 2-8 minutes; fundal
height 36 cm; cervix is firm, long, closed and
posterior. A urine dipstick is notable for 1+ glucose
with negative ketones. Which of the following is the
most likely diagnosis in this patient?
A. Appendicitis
B. Gestational diabetes
C. Braxton-Hicks contractions
D. First stage of labor
E. Dehydration
20. A 23-year-old G1P1 woman delivered a healthy
infant two days ago. She has had difficulty
breastfeeding despite multiple attempts. Her
nipples are sore and cracked and she is thinking
about exclusively bottlefeeding. The patient's
pregnancy was complicated by gestational
diabetes and the patient has chronic hypertension
and a history of an abnormal Pap. She had a cone
biopsy two years ago and had a normal Pap with
the current pregnancy. The patient's mother has a
history of endometrial and colon cancer and her
maternal grandmother and grandfather both had
fatal heart attacks in their early sixties.
Breastfeeding decreases the risk of which of the
following for this patient?
A. Type 2 diabetes
B. Coronary artery disease
C. Cervical cancer
D. Ovarian cancer
E. Colon cancer
21. A 23-year-old G1P1 woman develops a fever on the
third day after an uncomplicated Cesarean
delivery that was performed secondary to arrest of
descent. The only significant finding on physical
exam is moderate breast engorgement and mild
uterine fundal tenderness. What is the most likely
diagnosis in this patient?
A. Urinary tract infection
B. Mastitis
C. Endometritis
D. Wound cellulitis
E. Septic pelvic thrombophlebitis
C. Braxton Hicks contractions are characterized as short in duration, less
intense than true labor, and the discomfort as being in the lower abdomen and
groin areas. True labor is defined by strong, regular uterine contractions that
result in progressive cervical dilation and effacement. This patient's history
does not suggest she is in the first stage of labor. Patients with appendicitis
usually present with fever, decreased appetite, nausea and vomiting.
Gestational diabetes is diagnosed based on glucose challenge tests. The first
test with a 50 gram load is typically performed at 24-28 weeks gestation. It is
not abnormal for patients to have glucosuria. This finding is not diagnostic for
gestational diabetes. Patients with dehydration frequently present with
maternal tachycardia and have ketonuria.
D. Human milk is recognized by the American Academy of Pediatrics as an
optimal feeding for all infants. The American Academy of Pediatrics
recommends exclusive breastfeeding for the first six months after birth.
Physicians can influence a patient's feeding choice, and prenatal education is
important in the initiation and maintenance of breastfeeding. Nationally
representative surveys have noted that women were more likely to initiate
breastfeeding if their physicians or nurses encouraged it. Benefits to the
mother include increased uterine contraction due to oxytocin release during
milk let down and decreased blood loss. Breastfeeding is associated with a
decreased incidence of ovarian cancer. Some studies have reported a
decreased incidence of breast cancer. Breastfeeding has not been shown to
decrease the risk for developing coronary artery disease, cervical dysplasia
and cervical cancer or colon cancer in the mother. Breast milk is a major
source of Immunoglobulin A which is associated with a decrease of newborn's
gastrointestinal infections.
C.
The most common cause of postpartum fever is endometritis. The differential
diagnosis includes urinary tract infection, lower genital tract infection, wound
infections, pulmonary infections, thrombophlebitis, and mastitis. Endometritis
appearing in a postpartum period is most closely related to the mode of
delivery and occurs after vaginal delivery in approximately 2 percent of
patients and after Cesarean delivery in about 10 to 15 percent. Factors related
to increased rates of infection with a vaginal birth include prolonged labor,
prolonged rupture of membranes, multiple vaginal examinations, internal fetal
monitoring, removal of the placenta manually and low socioeconomic status.
Uterine fundal tenderness is commonly observed in patients with endometritis.
22. A 23-year-old G3P2 woman wants to exclusively breastfeed her baby.
She is deciding at which hospital she will deliver. Hospital policies that
promote breastfeeding include which of the following?
A. Uninterrupted sleep for the mother on her first night in the hospital
B. Use of a breast pump to help increase the milk supply
C. Use of pacifiers to prevent sore nipples
D. Unlimited access of mother to baby
E. Use of metoclopramide to increase the milk supply
23. A 24-year-old G0 woman presents to you for preconception
counseling. Her medical history is notable for type 1 diabetes mellitus,
hypertension, epilepsy, and hypothyroidism. Her medications include
insulin, methyldopa, valproic acid and levothyroxine. Based on her
medication exposure, her infant is at greatest risk of which of the
following anatomical defects?
A. Duodenal atresia
B. Skeletal anomalies
C. Renal tubular dysgenesis
D. Neural tube defects
E. Omphalocele
24. A 24-year-old G1P0 woman at 28 weeks gestation reports difficulty
breathing, cough and frothy sputum. She was admitted for preterm
labor 24 hours ago. She is a non-smoker. She has received 6 liters of
Lactated Ringers solution since admission. She is receiving
magnesium sulfate and nifedipine. Vital signs are: 100.2F (37.9C);
respiratory rate 24; heart rate 110; blood pressure 132/85; pulse
oximetry is 97% on a non-rebreather mask. She appears in distress.
Lungs reveal bibasilar crackles. Uterine contractions are regular every
three minutes. The fetal heart rate is 140 beats/minute. Labs show
white blood cell count 127,500/mL. Potassium and sodium are normal.
Which of the following has most likely contributed to this patient's
respiratory symptoms?
A. Increased plasma osmolality
B. Use of magnesium sulfate and nifedipine
C. Chorioamnionitis
D. Preterm labor
E. Increased systemic vascular resistance
25. A 24-year-old G1P0 woman at 34 weeks gestation is planning to
breastfeed her baby. Several hormones of pregnancy are responsible
in order for the breasts to produce milk. Which of the following
hormones is responsible for synthesis of milk?
A. Estrogen
B. Oxytocin
C. Cortisol
D. Prolactin
E. Human placental lactogen
D. Hospital policies that promote breastfeeding include
getting the baby on the breast within a half hour of
delivery and rooming-in for the baby to ensure frequent
breastfeeding on demand (i.e. unlimited access).
D. Valproic acid is associated with an increased risk for
neural tube defects, hydrocephalus and craniofacial
malformations. Insulin and methyldopa are not associated
with fetal defects. Omphalocele and duodenal atresia are
not increased in type 1 diabetic patients.
B. This patient has pulmonary edema. Plasma osmolality is
decreased during pregnancy which increases the
susceptibility to pulmonary edema. Common causes of
acute pulmonary edema in pregnancy include tocolytic
use, cardiac disease, fluid overload and preeclampsia. Use
of multiple tocolytics increases the susceptibility of
pulmonary edema, especially with the use of isotonic
fluids. Systemic vascular resistance is decreased during
pregnancy. Women with chorioamnionitis are also more
likely to develop pulmonary edema, but this is not usually
the main cause unless the patient is in septic shock and this
patient does not have chorioamnionitis.
D. Progesterone, estrogen, and placental lactogen, as well
as prolactin, cortisol, and insulin, appear to act in concert
to stimulate the growth and development of the milk-
secreting apparatus of the mammary gland. Prolactin is
responsible for the synthesis of milk, but although present
in large quantities during gestation, its action is inhibited by
the hormones of pregnancy, particularly estrogen and
progesterone. After delivery, large amounts of prolactin
continue to be secreted, milk is produced after the
inhibitory action of estrogen and progesterone is lifted.
26. A 24-year-old G1P0
woman at 41 weeks
gestation was noted to
have meconium-stained
amniotic fluid after an
amniotomy was
performed. What is the
most appropriate
management of this
patient to attempt to
prevent her newborn from
experiencing meconium
aspiration syndrome?
E. Meconium-stained amniotic fluid is present in 12-22% of women in labor. Meconium aspiration
syndrome occurs in up to 10% of infants who have been exposed to meconium-stained amniotic fluid. It
is associated with significant morbidity and mortality. The American College of Obstetrics and
Gynecology, the American Academy of Pediatrics and the American Heart Association recommend that
all infants with meconium-stained amniotic fluid should not routinely receive suctioning at the perineum.
If meconium is present and the newborn is depressed, the clinician should intubate the trachea and
suction meconium or other aspirated material from beneath the glottis. If the newborn is vigorous,
defined as having strong respiratory efforts, good muscle tone, and a heart rate greater than 100 beats
per minute, there is no evidence that tracheal suctioning is necessary. Injury to the vocal cords is more
likely to occur when attempting to intubate a vigorous newborn. Routine prophylactic amnioinfusion for
meconium-stained amniotic fluid is not recommended as there is no definitive benefit.

A. Initiate amnioinfusion
with sterile saline to dilute
the meconium-stained
amniotic fluid
B. Suction the oropharynx
and nasopharynx on the
perineum after the
delivery of the head but
before the delivery of the
shoulders
C. Suction the oropharynx
and nasopharynx on the
perineum immediately
after delivery before the
baby takes his first breath
D. Intubate the trachea
and suction meconium
and other aspirated
material from beneath the
glottis immediately after
delivery
E. Intubate the trachea
and suction meconium
and other aspirated
material from beneath the
glottis immediately after
delivery only if the infant
is depressed
27. A 24-year-old G1P0 woman has just delivered 37 week male twins. On your initial
assessment, you notice twin A is large and plethoric, and twin B is small and pale.
A complete blood count (CBC) is obtained on both twins. What is the most likely
potential neonatal risk in this case?
A. Twin A is at high risk for polycythemia
B. Twin A is at high risk for thrombocytopenia
C. Twin B is at high risk for thrombocytopenia
D. Twin B is at high risk for tachycardia
E. Twin B is at high risk for hyperbilirubinemia
28. A 24-year-old G1P0 woman presents in active labor at 39 weeks gestation. She
reports leaking fluid for the last two days. She develops a temperature of 102.0F
(38.9C) and fetal heart rate is 180 beats/min with minimal variability. Maternal
labs show: blood type O+; RPR non-reactive; HBsAg, negative; HIV negative; and
GBS unknown. What will be the expected appearance of the baby at delivery?
A. Vigorous, pink with normal temperature
B. Vigorous, pale with low temperature
C. Lethargic, pink with high temperature
D. Lethargic, pale with low temperature
E. Lethargic, pale with high temperature
29. A 24-year-old G4P2 woman at 34 weeks gestation complains of a cough and
whitish sputum for the last three days. She reports that everyone in the family
has been sick. She reports a high fever last night up to 102F (38.9C). She denies
chest pain. She smokes a half-pack of cigarettes per day. She has a history of
asthma with no previous intubations. She uses an albuterol inhaler, although she
has not used it this week. Vital signs are: temperature 98.6F (37C); respiratory
rate 16; pulse 94; blood pressure 114/78; peak expiratory flow rate 430 L/min
(baseline documented in the outpatient chart = 425 L/min). On physical
examination, pharyngeal mucosa is erythematous and injected. Lungs are clear
to auscultation. White blood cell count 8,700; arterial blood gases on room air
(normal ranges in parentheses): pH 7.44 (7.36-7.44); PO2 103 mm Hg (>100), PCO2
26 mm Hg (28-32), HCO3 19 mm Hg (22-26). Chest x-ray is normal. What is the
correct interpretation of this arterial blood gas?
A. Acute metabolic acidosis
B. Compensated respiratory alkalosis
C. Compensated metabolic alkalosis
D. Hypoventilation
E. Hyperventilation
A. This case is suggestive of twin-twin
transfusion syndrome (TTTS). Polycythemia is a
common complication for the plethoric twin.
TTTS is a complication of monochorionic
pregnancies. It is characterized by an
imbalance in the blood flow through
communicating vessels across a shared
placenta leading to under perfusion of the
donor twin, which becomes anemic and over
perfusion of the recipient, which becomes
polycythemic. The donor twin often develops
IUGR and oligohydramnios, and the recipient
experiences volume overload and
polyhydramnios that may lead to heart failure
and hydrops.
E. This patient clearly has chorioamnionitis. The
fetal tachycardia may be in response to the
maternal fever. Fetal tachycardia coupled with
minimal variability is a warning sign that the
infant may be septic. A septic infant will
typically appear pale, lethargic and have a high
temperature.
B. The increased minute ventilation during
pregnancy causes a compensated respiratory
alkalosis. Hypoventilation results in increased
PCO2 and the PO2 would be decreased if she
was hypoxic. A metabolic acidosis would have
a decreased pH and a low HCO3. The patient's
symptoms are most consistent with a viral
upper respiratory infection.
30. A 25-year-old G1P0 woman is seen for an C. The cardiac output increases up to 33% due to increases in both the heart rate and
initial obstetrical appointment at eight stroke volume. The SVR falls during pregnancy. Up to 95% of women will have a
weeks gestation. She has had a small systolic murmur due to the increased volume. Diastolic murmurs are always abnormal.
ventricular septal defect (VSD) since birth. The systemic vascular resistance (SVR) is normally greater than the pulmonary
She has no surgical history and no vascular resistance. If the pulmonary vascular resistance exceeds the SVR, right to left
limitations on her activity. Vital signs are: shunt will develop in the setting of a VSD, and cyanosis will develop.
respiratory rate 12; heart rate 88; blood
pressure 112/68. On physical examination:
her skin appears normal; lungs are clear to
auscultation; heart is a regular rate and
rhythm. There is a grade IV/VI coarse
pansystolic murmur at the left sternal
border, with a thrill. Chest x-ray and ECG
are normal. Which of the following is the
correct statement regarding cardiovascular
adaptation in this patient?

A. Approximately 2% of women will

normally have a diastolic murmur
B. Maternal pulmonary vascular resistance
is normally less than systemic vascular
resistance
C. The maternal cardiac output will increase
up to 33% during pregnancy
D. Maternal systemic vascular resistance
increases throughout pregnancy
E. The increase in cardiac output is only due
to the increase in the maternal stroke
volume
31. A 25-year-old G1P0 woman presents to B. Historically, the purpose of performing an episiotomy was to facilitate completion
labor and delivery with contractions. She is of the second stage of labor to improve both maternal and neonatal outcomes.
at 40 weeks gestation. Her cervix is 6 cm Maternal benefits were thought to include a reduced risk of perineal trauma,
dilated and 100% effaced. The fetus is in the subsequent pelvic floor dysfunction and prolapse, urinary incontinence, fecal
occiput anterior presentation at +1 station. incontinence, and sexual dysfunction. Current data does not demonstrate these
Fetal heart tones are reassuring with a theoretical maternal and fetal benefits and there are insufficient objective evidence-
baseline in the 140s, multiple accelerations based criteria to recommend episiotomy, and especially routine use of episiotomy.
and no decelerations. The patient had a The risk of incontinence increases with increasing degrees of pelvic trauma. One
fetal ultrasound three days ago which study of extended episiotomies demonstrated that the occurrence of a fourth-degree
reported an EFW of 2900 grams. The extension was more highly associated with anal incontinence. Performance of a
patient's older sister had a forceps assisted median episiotomy is the single greatest risk factor for third- or fourth-degree
vaginal delivery and has anal incontinence. lacerations. Avoiding the use of episiotomies may be the best way to minimize the risk
The patient would like to avoid having this of subsequent extensive damage to the perineum. This patient is in active labor and
same complication. Which of the following has a high chance of having a vaginal delivery. A cesarean delivery is not indicated.
management plans is most appropriate for There is no indication to perform a forceps or vacuum assisted vaginal delivery in this
this patient? patient at this time.

A. Cesarean delivery
B. Vaginal delivery with no episiotomy
C. Vaginal delivery with a small, controlled
midline episiotomy
D. Forceps assisted delivery with no
episiotomy
E. Vacuum assisted delivery with no
episiotomy
32. A 25-year-old G2P1 woman at 38 weeks gestation B. If an intrauterine pressure catheter is placed, and a significant amount
presents to labor and delivery with spontaneous onset of vaginal bleeding is noted, the possibility of placenta separation or
of labor and spontaneous rupture of membranes. Her uterine perforation should be considered. In this case, withdrawing the
cervical exam was 5 cm dilated, 90 percent effaced and catheter, monitoring the fetus and observing for any signs of fetal
0 station at presentation two hours ago. Presently, the compromise would be the most appropriate management. If the fetal
patient is uncomfortable and notes strong contractions. status is found to be reassuring, then another attempt at placing the
The cervical examination is unchanged from admission. catheter may be undertaken.
You decide to place an intrauterine pressure catheter
(IUPC). On placement, approximately 300 cc of frank
blood and amniotic fluid flow out of the vagina. What is
the most appropriate next step in the management of
this patient?

A. Emergent Cesarean delivery

B. Withdraw the IUPC, monitor fetus and then replace if
tracing reassuring
C. Begin amnioinfusion
D. Begin Pitocin augmentation
E. Keep IUPC in position and connect to tocometer
33. A 25-year-old G6P2 woman in active labor is treated A. You should give positive pressure ventilation and prepare to intubate
with mepiridine (Demerol). The patient reports the use the infant, if necessary. Any history of substance abuse may be a relative
of marijuana to control nausea during her pregnancy. contraindication to the use of naloxone (Narcan) because the mother
She quickly progresses from 4 cm to fully dilated in 1 may have used narcotics during the pregnancy and administration of
hour and is now pushing. A limp unresponsive infant is naloxone to the infant can cause life-threatening withdrawal. Stimulation
delivered. Heart rate is greater than 90 beats/minute. may not be sufficient for this infant. Suction will not necessarily stimulate
The infant has no respiratory effort. Which of the a respiratory effort.
following is the most appropriate next step in the
management of the neonate?

A. Give positive pressure ventilation and prepare to

intubate
B. Give positive pressure ventilation and prepare to give
naloxone
C. Give stimulation only and continue to monitor heart
rate
D. Suction thoroughly and check heart rate
E. Suction thoroughly and give naloxone
34. A 26-year-old African-American G1P0 woman presents B. Sickle cell anemia is an autosomal recessive condition that occurs in
to your office at seven weeks gestation with her 1/500 births in the African-American population. The carrier state, or
husband, who is also African-American. The patient's sickle-cell trait, is found in approximately 1/10 African-Americans. Since
brother has sickle cell anemia, and has been the patient's brother is affected, both of their parents have to be carriers.
hospitalized on numerous occasions with painful crises Each time two carrier parents for an autosomal recessive condition
requiring narcotic pain medication and blood conceive there is a 1/4 chance of having either an affected or an
transfusions. What are the odds that this couple will unaffected child and a 1/2 chance of having a child who is a carrier. Since
have a child with sickle cell anemia, if the carrier rate the patient is unaffected, she has a 1/3 chance of not being a carrier and
for sickle cell disease in the African American a 2/3 chance of being a carrier. The patient's husband has a 1/10 chance
population is 1/10? of being a carrier (the general population risk for African-Americans).
Thus, the chance that this couple will have a child with sickle cell anemia
A. 1 in 15 is: 2/3 X 1/10 X 1/4 = 1/60.
B. 1 in 60
C. 1 in 100
D. 1 in 160
E. 1 in 400
35. A 26-year-old G2P1 woman at 26 weeks B. This patient has three values on the three-hour glucose tolerance test that
gestation presents for a routine 50-gram were abnormal. Initial management should include teaching the patient how to
glucose challenge test. After receiving a one- monitor her blood glucose levels at home on a schedule that would include a
hour blood glucose value of 148 mg/dl, the fasting blood sugar and one- or two-hour post-prandial values after all three
patient has a follow up 100-gram 3-hour oral meals, daily. Goals for blood sugar management would be to maintain blood
glucose tolerance test with the following plasma sugars when fasting below 90 and one- and two-hour post-meal values below
values: Fasting 102 mg/dl (normal 95 mg/dl) 1- 120. A repeat glucose tolerance test would not add any value, as an abnormal
hour 181 mg/dl (normal 180 mg/dl) 2-hour 162 test has already been documented. Oral hypoglycemic agents and insulin are
mg/dl (normal 155 mg/dl) 3-hour 139 mg/dl not indicated at this time, as the patient may achieve adequate glucose levels
(normal 140 mg/dl) What is the most with diet modification alone. Gestational diabetes varies in prevalence. The
appropriate next step in the management of this prevalence rate in the United States has varied from 1.4 to 14% in various studies.
patient? Risk factors for gestational diabetes include: a previous large baby (greater than
9 lb), a history of abnormal glucose tolerance, pre-pregnancy weight of 110% or
A. Repeat the glucose tolerance test at 28 weeks more of ideal body weight, and member of an ethnic group with a higher than
gestation normal rate of type 2 diabetes, such as American Indian or Hispanic descent.
B. Begin a diabetic diet and blood glucose
monitoring
C. Begin a diabetic diet, an oral hypoglycemic
agent, and blood glucose monitoring
D. Begin a diabetic diet, insulin, and blood
glucose monitoring
E. Reassurance and routine prenatal care
36. A 26-year-old G2P1 woman at 41 weeks C. If the patient cannot deliver the infant with one or two pushes, the next best
gestation is brought in by ambulance. The choice given the fetal station and presentation is to perform an emergent outlet
emergency medical technician reports that a forceps or vacuum-assisted delivery. None of the other options offer an
pelvic examination performed 20 minutes ago expedient mode of delivery. Since the patient's heart rate is distinct from the fetal
when the patient had a severe urge to push heart rate, it is not necessary to check the fetal heart rate with an ultrasound. This
revealed that she was fully dilated and the fetal will potentially delay the time until delivery of the fetus. Amnioinfusion is not
station was +2. Fetal heart tones were confirmed indicated given the imminent delivery.
to be in the 150s, with no audible decelerations.
When the patient is placed on the fetal monitor,
the heart rate is noted to be in the 60s. The
maternal heart rate is recorded as 100. Without
pushing, the fetal scalp is visible at the introitus.
A repeat pelvic exam shows that the infant is in
the occiput anterior position. What is the most
appropriate next step in the management of this
patient?

A. Emergent Cesarean delivery

B. Amnioinfusion
C. Assisted operative vaginal delivery
D. Confirm the fetal heart rate with an internal
fetal scalp electrode
E. Use ultrasound to assess the fetal heart rate
37. A 27-year old G3P1 woman is admitted to the orthopedic service after open
reduction and internal fixation of her femur status post a motor vehicle
accident. Her past medical history is significant for diabetes (controlled with
metformin) and a history of a deep venous thrombosis three years ago while
taking an oral contraceptive. She has been receiving ibuprofen for pain
control and oxycodone for breakthrough pain as well as docusate sodium
(Colace). Additionally, anticoagulation therapy was began with IV heparin,
and is now therapeutic on warfarin. At a follow up visit, she has a positive
pregnancy test and an ultrasound confirms a six-week intrauterine
pregnancy. Which of the following medications should be discontinued now?
A. Metformin
B. Docusate sodium
C. Ibuprofen
D. Oxycodone
E. Warfarin
38. A 28-year-old G0 woman presents with her husband for preconception
counseling. Her family is Ashkenazi Jewish from Poland. Her husband is 30
years old and is also Jewish. They seek information about preconception and
prenatal screening. The patient is at increased risk for having a fetus affected
with all of the following conditions except:
A. Fanconi anemia
B. Tay-Sachs disease
C. Beta thalassemia anemia
D. Cystic fibrosis
E. Niemann-Pick disease
39. A 28-year-old G1P0 internal medicine resident at 34 weeks gestation had
pulmonary function tests performed two days ago because she was feeling
slightly short of breath. She is a non-smoker, and has no personal or family
history of cardiac or respiratory disease. Vital signs are: respiratory rate 16;
pulse 90; blood pressure 112/70; temperature 98.6F (37C); oxygen
saturation is 99% on room air. On physical examination: lungs are clear;
abdomen non-tender; fundal height is 34 cm. The results of the pulmonary
function tests are: inspiratory capacity (IC) increased; tidal volume (TV)
increased; minute ventilation increased; functional reserve capacity (FRC)
decreased; expiratory reserve capacity (ERC) decreased; residual volume
(RV) decreased. What is the next best step in the evaluation of this patient?
A. Routine antenatal care
B. Chest x-ray
C. Arterial blood gas
D. Spiral CT of the lungs
E. Echocardiogram
40. A 28-year-old G1P0 woman is at 15 weeks gestation. Her husband's cousin
has moderate mental retardation. The most common cause of inherited
mental retardation in this patient's child would be?
A. Undiagnosed phenylketonuria (PKU)
B. Neonatal hypothyroidism
C. Fragile X syndrome
D. Down syndrome
E. Autism
E. Of the medications she is currently taking, none
are contraindicated at this gestational age.
Ibuprofen is safe to take until around 32 weeks
gestation, when premature closure of the ductus
arteriosis is a risk. While heparin is safe during
pregnancy, warfarin has known teratogenic affects
and should not be given. If continued
anticoagulation is necessary, low molecular weight
heparin is the drug of choice.
C. Fanconi anemia, Tay-Sachs disease, Cystic
Fibrosis, and Niemann-Pick disease are all
autosomal recessive conditions that occur at an
increased incidence in Jews of Ashkenazi descent.
The Beta thalassemia is seen mainly in
Mediterranean populations.
A. The results of her PFT are consistent with normal
physiologic changes in pregnancy. Inspiratory
capacity increases by 15% during the third trimester
because of increases in tidal volume and inspiratory
reserve volume. The respiratory rate does not
change during pregnancy, but the TV is increased
which increases the minute ventilation, which is
responsible for the respiratory alkalosis in
pregnancy. Functional residual capacity is reduced
to 80% of the non-pregnant volume by term. These
combined lead to subjective shortness of breath
during pregnancy.
C. Fragile X syndrome is the most common form of
inherited mental retardation. The syndrome occurs
in approximately 1 in 3,600 males and 1 in 4,000 to
6,000 females. Down syndrome is genetic but the
majority of cases are not inherited.
41. A 28-year-old G1P0 woman
presents for prenatal care. Her
periods have been irregular
and she does not recall when
the last one occurred. She is
healthy and denies any
medical problems. The uterus
is 10 weeks in size and there
are no adnexal masses. At this
point in time, what is the best
way to date the pregnancy?
D. All the above can potentially be used to help date a pregnancy; however, ultrasound
measurement of crown-rump length is considered the most reliable (+/- 4 to 5 days) in the first
trimester. Other means to date the pregnancy include: fetal heart tones that have been
documented for 20 weeks by a non-electronic fetoscope or for 30 weeks by Doppler; it has been
36 weeks since a positive serum or urine Beta-hCG pregnancy test was performed by a reliable
laboratory; an ultrasound measurement of the crown-rump length obtained at six to twelve weeks
supports a gestational age of at least 39 weeks; and an ultrasound obtained at 13-20 weeks
confirms the gestational age of at least 39 weeks determined by clinical history and physical
examination. Clearly, these means are not as useful in early pregnancy, but in confirming the length
of pregnancy. Serum progesterone levels are used to help establish if a pregnancy is progressing
normally and not an ectopic, miscarriage, or fetal demise.

A. Serum Progesterone
B. Quantitative serum Beta-
hCG
C. Ultrasound measurement,
gestational sac
D. Ultrasound measurement,
crown-rump length
E. Uterine size on pelvic exam
42. A 28-year-old G1P1 woman D. Engorgement commonly occurs when milk comes in. Strategies that may help include frequent
delivered three days ago and nursing, taking a warm shower or warm compresses to enhance milk flow, massaging the breast and
desires to breastfeed her hand expressing some milk to soften the breast, wearing a good support bra and using an
infant, but is having problems analgesic 20 minutes before breastfeeding.
since her milk came in with full
tender breasts. She is
uncomfortable and has
engorged breasts. Which of
the following strategies may
help relieve her discomfort?

A. Discontinue breastfeeding
for 24 hours to decrease the
milk supply
B. Cover the breast with cool
lettuce leaves
C. Increase the interval
between breastfeeding
sessions to decrease the milk
supply
D. Nurse every 1.5-3 hours
around the clock
E. Don't wear a bra until the
engorgement subsides
43. A 28-year-old G3P3 woman status post an
uncomplicated spontaneous vaginal delivery of 4150
gram infant experiences profuse vaginal bleeding of 700
cc. Prior obstetric history was notable for a previous low
uterine segment transverse Cesarean section, secondary
to transverse fetal lie. The patient had no antenatal
problems. The placenta delivered spontaneously without
difficulty. Which of the following is the most likely cause
of this patient's hemorrhage?
C. Postpartum hemorrhage (PPH) is an obstetrical emergency that can
follow vaginal or Cesarean delivery. Uterine atony is the most common
cause of PPH and occurs in one in every twenty deliveries. It is important
to detect excessive bleeding quickly and determine an etiology and
initiate the appropriate treatment as excessive bleeding may result in
hypovolemia, with associated hypotension, tachycardia or oliguria. The
most common definition of PPH is an estimated blood loss of greater
than or equal to 500 ml after vaginal birth, or greater than or equal to
1000 ml after Cesarean delivery.

A. Vaginal lacerations
B. Cervical lacerations
C. Uterine atony
D. Uterine dehiscence
E. Uterine rupture
44. A 29-year-old G1P1 woman had an uncomplicated B. Although the side lying position is a good one for breastfeeding, it is
vaginal delivery and breastfed immediately postpartum. important for mother and baby to be belly-to-belly in order for the
She has a significant amount of abdominal soreness infant to be in a good position to latch on appropriately, taking a large
secondary to a tubal ligation performed on postpartum part of the areola into its mouth. The pain experienced by the patient
day two. She is breastfeeding on her side with the baby from her tubal may be interfering with appropriate position and she
lying on her side, well away from the abdomen to should be counseled about a different, more comfortable position.
prevent pain at the incision site. She developed bleeding
and cracked nipples. Which of the following is the most
likely cause?

A. Feedings not frequent enough

B. Poor positioning of infant
C. Feedings too frequent
D. Not enough milk production
E. Irritation from the bra
45. A 29-year-old G2P1 woman at 36 weeks gestation is seen C. Intrauterine growth restriction is typically seen in women with pre-
for management of her gestational diabetes. Despite existing diabetes and not with gestational diabetes. Shoulder dystocia,
diet modification, the patient has required insulin to metabolic disturbances, preeclampsia, polyhydramnios and fetal
control her serum glucose levels. She has gained 25 macrosomia are all associated risks of gestational diabetes.
pounds with the pregnancy. Which of the following
complications is least likely to occur?

A. Polyhydramnios
B. Neonatal hypoglycemia
C. Intrauterine growth restriction
D. Preeclampsia
E. Fetal macrosomia
46. A 30-year-old G0 woman presents with her husband for
preconception counseling. The patient is of Ashkenazi Jewish
descent. Her husband is Irish. The patient has a brother who
has a child diagnosed with attention deficit hyperactivity
disorder. Which of the following genetic diseases is the most
likely to affect their future children?
A. Canavan disease
B. Bloom syndrome
C. Cystic fibrosis
D. Tay-Sachs disease
E. Gaucher's disease
47. A 30-year-old G1P0 woman with type 1 diabetes mellitus
presents at 10 weeks gestation for a routine visit. She smokes
a half a pack of cigarettes per day. Her hemoglobin A1C
level is 9.7. What structural anomaly is the fetus at highest
risk of developing?
A. Cardiac anomalies
B. Caudal regression malformation
C. Hydrocephalus
D. Microcephaly
E. Limb reductions
48. A 30-year-old G1P1 woman is breastfeeding her baby and
feels there is not enough milk. She is pumping in order to
improve the supply of milk. You tell her that more frequent
suckling would be better as it will stimulate which of the
following hormones?
A. Progesterone
B. Insulin
C. Cortisol
D. Prolactin
E. Oxytocin
49. A 30-year-old G1P1 woman who underwent an urgent
vacuum extraction of a baby girl two months ago is
experiencing persistent depressive symptoms suggestive of
postpartum depression. She is recently divorced and has no
immediate family or close friends. She works as a mechanic
in a local garage and is planning on going back to school.
She contemplated terminating the pregnancy but ultimately
decided to have the baby despite no support from her ex-
husband. She has a history of depression in the past but has
not required any medications for the last three years. Which
of the following is her most significant risk factor for
postpartum depression?
A. Single parent
B. Consideration to terminate the pregnancy
C. Personal history of depression
D. Urgent delivery
E. Social isolation
C. Non-Hispanic white individuals, including Ashkenazi Jews, are at
increased risk for being carriers for cystic fibrosis. The carrier
frequency is approximately 1/25 in the non-Hispanic white
population. Since the patient's husband is not of Ashkenazi Jewish or
French Canadian descent, he is not at increased risk for being a
carrier for Tay-Sachs disease. The carrier frequency for Tay-Sachs
disease is estimated at 1/30 for Ashkenazi Jews. The gene occurs at
a much lower frequency (1 in 300) in most other populations.
Canavan disease, Bloom syndrome and Gaucher's disease occur at
an increased incidence in the Ashkenazi Jewish population. The
carrier frequency for Canavan is 1:55, for Bloom 1:134, and for
Gaucher is approximately 1/15 in Ashkenazi Jews.
A. Women with poorly controlled diabetes immediately prior to
conception and during organogenesis have a four- to eight-fold risk
of having a fetus with a structural anomaly. The majority of lesions
involve the central nervous system (neural tube defects) and the
cardiovascular system. Genitourinary and limb defects have also
been reported. Although caudal regression malformation occurs at
an increased incidence in individuals with diabetes, this condition is
very rare.
E. While prolactin is responsible for milk production, oxytocin is
responsible for milk ejection. Production of oxytocin is stimulated by
suckling which works better than a breast pump for stimulating the
secretion of milk. Cortisol and insulin act in concert with other
hormones to stimulate the growth and development of the milk-
secreting apparatus.
C. The most significant risk factor for developing postpartum
depression is the patient's prior history of depression. Other risk
factors for postpartum depression include marital conflict, lack of
perceived social support from family and friends, having
contemplated terminating the current pregnancy, stressful life
events in the previous twelve months, and a sick leave in the past
twelve months related to hyperemesis, uterine irritability or
psychiatric disorder.
50. A 30-year-old G2P0 woman at 38 weeks gestation has just
delivered a male infant. She has a history of type 1 diabetes
since age 11. Maternal labs show: blood type B+; RPR non-
reactive; HBsAg negative; HIV negative; and GBS negative.
She had moderate control of blood sugar during her
pregnancy. Which of the following would be the most likely
finding in the newborn?
B. Small babies are more common with type 1 diabetes than with
gestational diabetes, and the blood sugar level of all newborns of
diabetic mothers should be monitored closely after delivery, as
they are at increased risk for developing hypoglycemia.
Macrosomic (large) infants are typically associated with gestational
diabetes.

A. Large and hypoglycemic

B. Small and hypoglycemic
C. Large and hyperglycemic
D. Small and hyperglycemic
E. Normal size and euglycemic
51. A 30-year-old G2P1 woman has an ultrasound at 42 weeks for
size greater than dates. The fetus had an isolated enlarged
head measurement with a BPD of 11 cm, but otherwise
appeared to have normal femur length and abdominal
circumference. Polyhydramnios is noted. The estimated fetal
weight is 3900 g. There is a 10 cm lower uterine segment
fibroid protruding into the uterine cavity. The fetus is in the
vertex presentation and the fetal head is above the level of
the uterine fibroid. Which of the following is an indication for
primary Cesarean section in this patient?
A. Uterine fibroids located in the lower uterine segment may
obstruct labor by preventing the fetal head from entering the
pelvis. A fetal head with measurements greater than 12 cm could
benefit from delivery by Cesarean section. The fetus in the case
presented does not necessarily have hydrocephalus. The fetus
does not have macrosomia which may be defined as an estimated
fetal weight greater than 4000 grams in a diabetic and greater than
4500 grams in a non-diabetic patient. Macrosomia defined as
greater than 4000 grams, 42 weeks gestation, and polyhydramnios
are not indications for primary Cesarean section.

A. Uterine fibroid
B. Fetal hydrocephalus
C. Polyhydramnios
D. Macrosomia
E. 42 weeks gestation
52. A 32-year-old G1 woman
with an IVF conceived
pregnancy at 12 weeks
gestation has a slightly
increased fetal nuchal
translucency (3.0 mm), but
her first trimester screen
shows no increased risk for
Down syndrome or Trisomy
18. Still concerned about the
increased nuchal
translucency, the patient
requests additional testing
to exclude chromosomal
abnormalities. Which of the
following is the next best
step to rule out a
chromosomal abnormality in
this patient?
A. Cell-free DNA testing
B. Genetic sonogram
C. Amniocentesis
D. Sequential screen
E. Detailed sonogram and
fetal echocardiogram at
approximately 18 - 20 weeks
gestation
C. Amniocentesis is a diagnostic test that may detect Down syndrome as well as other chromosomal
abnormalities. Cell-free DNA testing detects over 99% of cases of Down syndrome. The first trimester
screen, which consists of a nuchal translucency and maternal serum PAPP-A and beta-hCG, yields an
85% detection rate for Down syndrome. The NT is the measurement of the fluid collection at the back
of the fetal neck in the first trimester. A thickened NT may be associated with fetal chromosomal and
structural abnormalities as well as a number of genetic syndromes. Patients who desire non-invasive
assessment of their risk for aneuploidy can have first trimester screen (a fetal nuchal translucency (NT)
measurement and a maternal serum PAPP-A) and a second trimester quadruple screen. The
sequential screen which combines the first trimester screen with a quadruple screen yields a 95%
detection rate for Down syndrome at a 5% false-positive rate. Since the fetus in this case had a
thickened NT, this patient should be scheduled to have a detailed fetal ultrasound and
echocardiogram at 18-20 weeks to rule out anomalies. However, it is not possible to diagnose a
chromosomal abnormality with an ultrasound. Similarly, although genetic sonograms (targeted
sonogram) focus on markers associated with Down syndrome, they are not diagnostic. Approximately
50% of cases of Down syndrome do not have ultrasound findings. Of note, the American Congress of
Obstetrics and Gynecology (ACOG) recommends that all patients be offered aneuploidy screening
and invasive prenatal diagnosis as indicated.
53. A 32-year-old G2P1 woman is 20 weeks gestation. Her prior E. Cultures for group B streptococcus are not required in women
pregnancy was complicated by postpartum endometritis who have group B streptococcal bacteriuria during the current
and her son was diagnosed with early-onset neonatal pregnancy or who have previously given birth to a neonate with
sepsis due to group B streptococcus. Which of the following early-onset group B streptococcal disease because these women
management options regarding Group B streptococcus is should receive intrapartum antibiotic prophylaxis. Universal screening
most appropriate for this patient? with a recto-vaginal culture at 35-37 weeks of gestation is
recommended for all women who do not have an indication for
A. Recto-vaginal culture at 35-37 weeks and antibiotic intrapartum antibiotic prophylaxis. All women with positive cultures
treatment during labor if positive for group B streptococci should receive intrapartum antibiotic in
B. Recto-vaginal culture at 35-37 weeks and antibiotic labor unless a cesarean delivery is performed before onset of labor
treatment at the time the culture result returns if positive in a woman with intact amniotic membranes.
C. Recto-vaginal culture at 24-28 weeks and antibiotic
treatment during labor if positive
D. Recto-vaginal culture at 24-28 weeks and antibiotic
treatment at the time the culture result returns if positive
E. Do not perform recto-vaginal cultures and treat with
antibiotics during labor
54. A 32-year-old G2P2 woman has just had a spontaneous A. With delivery, there is a rapid and profound decrease in the levels
vaginal delivery. She is concerned that no breast milk is yet of progesterone and estrogen, which removes the inhibitory
being produced when she tries to feed her baby. You influence of progesterone on the production of alpha-lactalbumin by
reassure her that colostrum is rich in protein and nutrients, the rough endoplasmic reticulum. The increased alpha-lactalbumin
and that her breast milk will come in 2-3 days when which serves to stimulate lactose synthase and ultimately to increase milk
of the following hormones have been cleared? lactose. Progesterone withdrawal allows prolactin to act unopposed
in its stimulation of alpha-lactalbumin production. This may take up to
A. Estrogen and progesterone two days.
B. Estrogen and oxytocin
C. Human placental lactogen and prolactin
D. Progesterone and prolactin
E. Growth hormone and GnRH
55. A 32-year-old G3P1 woman at 37 weeks gestation is B. A usual protocol is to start AZT immediately after delivery. HIV
admitted to labor and delivery for a scheduled repeat testing begins at 24 hours. There is no reason to isolate the infant
Cesarean delivery. Maternal labs show: HIV positive; blood even though the mother is PPD positive, because her CXR is negative.
type B+; RPR non-reactive; HBsAg negative; GBS negative; Breastfeeding would not be encouraged in a mother with HIV.
PPD positive; CXR negative. She received adequate
antiretroviral therapy prior to and during the pregnancy.
Her viral load was undetectable throughout the second and
third trimester. A live male infant is delivered with Apgar
scores of 9 and 9 at 1 and 5 minutes, respectively. Which of
the following is the most appropriate next step in the
management of the newborn?

A. Order HIV testing on the infant immediately on

admission to the nursery
B. Treat the infant with zidovudine (AZT) immediately after
delivery
C. Encourage breastfeeding
D. Start zidovudine at 24 hours of life
E. Isolate the infant from the other infants in the nursery
56. A 32-year-old G3P2 woman has delivered a previous
child with anencephaly. What is the appropriate
recommended dose of folic acid for this woman?
A. 0.4 mg
B. 0.8 mg
C. 1.0 mg
D. 4 mg
E. 8 mg
57. A 33-year-old G2P1 woman delivered a male infant
after a precipitous second stage. On initial assessment,
the infant has no respiratory effort. You decide to
proceed with positive pressure ventilation. Which of the
following techniques will impede positive pressure
ventilation on this newborn?
A. Adjusting head position to modified flex position
B. Adjusting the head to sniffing position
C. Securing mask for a good seal
D. Compressing the bag just until chest rise is seen
E. Having the oxygen flow at minimum 10 L/minute
58. A 33-year-old G5P4 woman just delivered her fourth
baby without complications. She had gained 50 pounds
during this pregnancy and would like to begin a weight
loss program as soon as possible. She desires long-
term effective contraception, because she doubts she
wants more children. She also desires to breastfeed
exclusively for six months and has had trouble with this
in the past. Which of the following is the most
appropriate contraceptive choice for this patient?
A. Depot medroxyprogesterone
B. Combined estrogen-progestin contraceptives
C. Tubal ligation
D. Intrauterine device (IUD)
E. Essure (Bilateral occluding tubal coils)
59. A 34-year-old G1P0 woman at 39 weeks gestation
presents in active labor. Her cervical examination an
hour ago was 5 cm dilated, 90 percent effaced and 0
station. She just had spontaneous rupture of
membranes and is found to be completely dilated with
the fetal head is at +3 station. The fetal heart rate
tracing is shown below. What is the most likely etiology
for these decelerations?
(late decels)
A. Oligohydramnios
B. Rapid change in descent
C. Umbilical cord compression
D. Uteroplacental insufficiency
E. Head compression
D. In 1991, the Centers for Disease Control and Prevention recommended
that all women with a previous pregnancy complicated by a fetal neural
tube defect ingest 4 mg of folic acid daily before conception and through
the first trimester. In one analysis, this dose of folic acid in women at high
risk reduced the incidence of neural tube defects by 85%. According to
ACOG, tThe recommended dose for non-high risk patients is at least 0.6
mg/day.
B. The sniffing position (tilting the neonate's head back and lifting the chin)
is the correct position for application of positive pressure ventilation in a
newborn infant. It is important to also secure the mask to the infant's face
and to observe an initial chest rise. A recommended rate of oxygen flow
is 10 L/minute.
D. A paucity of data exists regarding the effect of hormonal contraception
on breastfeeding. There are concerns that hormones, especially estrogen,
may have a negative impact on the quantity or quality of breast milk.
Although Depot medroxyprogesterone is a progesterone only
contraceptive, it is known to cause weight gain and would not be a good
choice in this patient. The IUD is the best choice because it is long term
but reversible, and does not affect milk production. Tubal ligation and
Essure are permanent sterilization and would not be best for a patient
who may desire more children.
D. This patient is having late decelerations. Late decelerations are
associated with uterine contractions. The onset, nadir, and recovery of the
decelerations occur, respectively, after the beginning, peak and end of
the contraction. Late decelerations are associated with uteroplacental
insufficiency. A rapid change in cervical dilation and descent are not
associated with late decelerations. Umbilical cord compression is
associated with variable decelerations. Oligohydramnios can increase a
patient's risk of having umbilical cord compression; however, it does not
cause late decelerations. Head compression is associated with early
decelerations.
60. A 34-year-old G2P1 woman is 40 weeks gestation. She
was admitted to labor and delivery in active labor 2
hours ago. Her cervix was 6 cm dilated and 100%
effaced on admission. Her fetus was vertex and - 3
station. You are called to examine the patient after she
experiences spontaneous rupture of membranes. The
cervix is completely dilated and the fetal head is
occiput anterior (OA) at +1 station. You palpate a 5 cm
long section of umbilical cord in the patient's vagina.
The fetal heart tracing is reassuring. The baseline is
130 beats per minute. There are multiple accelerations
and no decelerations. The patient is having regular
uterine contractions every 2-3 minutes. She has an
epidural and is not feeling the contractions. What is
the most appropriate next step in the management of
this patient?
A. Allow for passive descent of the fetal head with
continuous fetal monitoring
B. Have the patient start pushing with the contractions
C. Gently attempt to replace the umbilical cord
segment back up into the uterus
D. Perform a forceps assisted vaginal delivery
E. Elevate the fetal head with a vaginal hand and
perform a Cesarean delivery
61. A 34-year-old G2P1 woman presents at 17 weeks
gestation. She did not seek preconception counseling
and is worried about delivering a child with Down
syndrome, given her maternal age. She has no
significant medical, surgical, family or social history.
Which of the following tests is most effective in
screening for Down syndrome in this patient?
A. Cell-free DNA screen
B. Triple screen
C. Quadruple screen
D. Maternal serum alpha fetoprotein level
E. Nuchal translucency measurement with serum
PAPP-A (pregnancy associated plasma protein-A) and
free Beta-hCG level
E. This patient has an umbilical cord prolapse. Although fetal surveillance is
reassuring, the most appropriate management is to continue to elevate the
fetal head with a hand in the patient's vagina and call for assistance to
perform a Cesarean delivery. It is important to elevate the fetal head in an
attempt to avoid compression of the umbilical cord. Once an umbilical
cord prolapse is diagnosed, expeditious arrangements should be made to
perform a cesarean section. It is not appropriate to replace the umbilical
cord into the uterus or allow the patient to continue to labor or perform a
forceps-assisted vaginal delivery.
A. Cell-free DNA screening is the most effective screening test for Down
syndrome. The test may be performed as early as 9 weeks gestation and
until delivery. The test detects over 99% of cases of Down syndrome. The
quadruple test (maternal serum alpha fetoprotein, unconjugated estriol,
human chorionic gonadotropin, and inhibin A) may be used to screen for
Down syndrome in the second trimester. Down syndrome occurs in about 1
in 800 births in the absence of prenatal intervention. The efficacy of
screening for Down syndrome is improved when additional components
are added to the maternal serum alpha fetoprotein screening. The addition
of unconjugated estriol and human chronic gonadotropin (the Triple
Screen) results in a 69% detection rate for Down syndrome. Adding inhibin
A to produce a quadruple screen achieves a detection rate of 80-85%.
Nuchal translucency measurement with maternal serum PAPP-A and free
Beta-hCG (known as the combined test) is a first trimester screen for Down
syndrome. It detects approximately 85% of cases of Down syndrome at a
5% false positive rate.
62. A 34-year-old G3P1 woman at 26 weeks gestation reports "difficulty
catching her breath," especially after exertion for the last two
months. She is a non-smoker. She does not have any history of
pulmonary or cardiac disease. She denies fever, sputum, cough or
any recent illnesses. On physical examination, her vital signs are:
blood pressure 108/64; pulse 88; respiratory rate 15; and she is
afebrile. Pulse oximeter is 98% on room air. Lungs are clear to
auscultation. Heart is regular rate and rhythm with II/VI systolic
murmur heard at the upper left sternal border. She has no lower
extremity edema. A complete blood count reveals a hemoglobin of
10.0 g/dL. What is the most likely explanation for this woman's
symptoms?
C. Physical examination findings are not consistent with
pulmonary embolus (e.g tachycardia, tachypnea, hypoxia,
chest pain, signs of a DVT) or mitral stenosis (diastolic
murmur, signs of heart failure). Physiologic dyspnea of
pregnancy is present in up to 75% of women by the third
trimester. Peripartum cardiomyopathy is an idiopathic
cardiomyopathy that presents with heart failure secondary to
left ventricular systolic function towards the end of
pregnancy or in the several months following delivery.
Symptoms include fatigue, shortness of breath, palpitations,
and edema. The history and physical do not suggest a
pathologic process, nor does her hemoglobin level.

A. Pulmonary embolism
B. Mitral valve stenosis
C. Physiologic dyspnea of pregnancy
D. Peripartum cardiomyopathy
E. Anemia
63. A 34-year-old G4P2 woman at 18 weeks gestation presents with A. Thyroid binding globulin (TBG) is increased due to
fatigue and occasional headache. She has a sister with Grave's increased circulating estrogens with a concomitant increase
disease. On physical exam, vital signs are normal. BMI is 27. Thyroid in the total thyroxine. Free thyroxine (T4) remains relatively
is difficult to palpate due to her body habitus. The remainder of her constant. Total triiodothyroxine (T3) levels also increase in
exam is unremarkable. Thyroid function studies show: pregnancy while free T3 levels do not change. In a pregnant
patient without iodine deficiency, the thyroid gland may
Results Reference Range increase in size up to 10%. This patient's thyroid function is
TSH 1.8 mU/L 0.30 - 5.5 mU/L normal for pregnancy, and her symptoms of fatigue can be
Free T4 1.22 ng/dL 0.76 - 1.70 ng/dL explained by other physiologic changes in pregnancy,
Total T4 14.2 ng/dL 4.9 - 12.0 ng/dL including anemia, difficulty with sleep, and increased
Free T3 3.4 ng/dL 2.8 - 4.2 ng/dL metabolic demand.
Total T3 200 ng/dL 80 - 175 nd/dL
What is the next best step in the management of this patient?

A. Continue routine prenatal care

B. Check anti-thyroid antibody levels
C. Obtain a thyroid ultrasound
D. Initiate propylthiouracil
E. Initiate methimazole
64. A 34-year-old G4P4 woman is diagnosed with endometritis E. Bacterial isolates related to postpartum endometritis are
following a Cesarean delivery three days ago. Which of the usually polymicrobial resulting in a mix of aerobes and
following is the most likely causative agent(s) of endometritis in this anaerobes in the genital tract. The most causative agents are
patient? Staphylococcus aureus and Streptococcus.

A. Aerobic streptococcus
B. Anaerobic streptococcus
C. Aerobic staphylococcus
D. Anaerobic staphylococcus
E. Aerobic and anaerobic bacteria
65. A 35-year old G2P1 woman is at 11 weeks
gestation. She had a triple screen with her last
pregnancy and would like to have aneuploidy
screening with the current pregnancy. Which
of the following screening tests will provide
the highest detection rate for trisomy 21 for
this patient?
A. First trimester combined test
B. Sequential screen
C. Quad screen
D. Cell-free DNA screen
E. Serum integrated screen
66. A 35-year-old G3P2 woman presents for her
initial prenatal care visit at 15 weeks gestation,
according to her last menstrual period. She
reports that a home pregnancy test was
positive about five weeks ago. Review of her
history is unremarkable and her entire family
is in good health. Physical examination reveals
a ten-week size uterus. Which of the following
is the most appropriate next step in
establishing this pregnancy's gestational age?
A. Checking fetal heart tones
B. Hysterosonogram
C. Quantitative Beta-hCG
D. Obstetrical ultrasound
E. Quadruple screen
67. A 35-year-old G3P0020 woman presents at 11
weeks gestation for chorionic villus sampling
(CVS). She has had two prior first trimester
losses. What is the risk of miscarriage
associated with CVS in this patient?
A. 0.1%
B. 1%
D. 10%
E. 15%
C. 5%
D.
All of the tests screen for trisomy 21 and trisomy 18. Cell-free DNA screening has a
trisomy 21 detection rate of over 99% at a 0.2% false-positive rate. The other
options may also be used to screen for trisomy 21. Detection rates provided at a
5% false positive screen rate.
First trimester combined test: first trimester nuchal translucency, PAPP-A
(pregnancy associated plasma protein A) and Beta-hCG - 85% Detection Rate
Triple screen: second trimester AFP (alpha fetoprotein), Beta-hCG, uE3
(unconjugated estriol) - 69% Detection Rate
Quad screen: (second trimester Triple screen + inhibin A) - 81% Detection Rate
Sequential screen: (first trimester NT and PAPP-A + second trimester quad
screen) - 93% Detection Rate
Serum integrated screen, when unable to obtain nuchal translucency: (first
trimester PAPP-A + second trimester quad screen) - 85-88% Detection Rate
D. The patient's gestational age based on her LMP and the findings on physical
exam are discordant. In this case, the most reliable method of confirming
gestational age is a dating ultrasound. A quantitative Beta-hCG will not reliably
predict the gestational age. The uterine size on physical exam is not the most
accurate way to date a pregnancy. An ultrasound performed between 14 and 15
6/7 weeks gestation should be used to date the pregnancy if there is greater than
a 7 day discrepancy from the menstrual dates or more than a 10 day discrepancy if
the ultrasound is performed between 16 and 21 6/7 weeks. . First trimester
ultrasound provides the most accurate assessment of gestational age and can give
an accurate estimated date of confinement (EDC) to within 3-5 days.
B. The risk of fetal loss associated with CVS is approximately 1% and is not related
to her prior miscarriage history.
68. A 35-year-old G4P3 woman comes in for a C. In addition to the more common symptoms of depression, the postpartum patient
postpartum visit. She had a normal may manifest a sense of incapability of loving her family and manifest ambivalence
uncomplicated vaginal delivery two weeks toward her infant. Anhedonia is an inability to experience pleasure from normally
ago. She has a history of postpartum pleasurable life events such as eating, exercise, and social or sexual interaction.
depression, which required treatment with
antidepressants with her last pregnancy.
Which of the following signs or symptoms
of postpartum depression are most useful
to distinguish it from postpartum blues and
normal changes that occur after delivery?

A. Anhedonia
B. Crying spells
C. Ambivalence toward the newborn
D. Sleeplessness
E. Weight loss
69. A 35-year-old G5P4 woman status post E. The most likely complication she will experience is future pregnancy. The failure
vaginal delivery desires postpartum tubal rate associated with surgical sterilization is approximately one percent. Approximately
ligation. In obtaining informed consent, one-third of pregnancies after tubal ligation are ectopic. The existence of a "post-
which of the following is the most likely risk tubal ligation syndrome" in which disruption of blood flow in the area of the fallopian
associated with this procedure? tubes leads to menstrual dysfunction and dysmenorrhea has not been substantiated.
Tubal ligation appears to have a protective effect on ovarian cancer incidence. There
A. Chronic cyclic pain with menstrual cycles is no proven association between decreased sexual enjoyment and tubal ligation.
B. Increased risk for ovarian cancer Tubal ligations may be performed under regional or general anesthesia. Postpartum
C. Decreased enjoyment with sexual tubal ligations are generally performed using a spinal or epidural anesthesia. The risk
intercourse of aspiration are low and range from 1/1000 to 1/14,000.
D. Aspiration with general anesthesia
E. Unplanned pregnancy
70. A 36-year-old woman requests prenatal B. Chorionic villus sampling (CVS) is a prenatal test that can detect genetic and
diagnosis. She is healthy and excited about chromosomal abnormalities of a fetus. The loss rate with amniocentesis is quoted as
finally getting pregnant. She is interested in 0.5% vs. ~1 to 3% for chorionic villus sampling. CVS is performed between 10 and 12
genetic counseling and asks about the weeks gestation, while amniocentesis is performed after 15 weeks. Early CVS (<10
advantages of chorionic villus sampling weeks gestation) is associated with an increase in rare limb abnormalities. It is more
versus amniocentesis. Which of the likely that a CVS will involve multiple attempts - a failure to obtain an adequate
following is true when chorionic villus sample of cells and the woman requiring a repeat test later on - when compared with
sampling is compared to amniocentesis? amniocentesis. Pregnancies complicated by isoimmunization can be followed by serial
assessment of the amniotic fluid for bilirubin.
A. Reduced post-procedure loss rate
B. Performed earlier
C. More likely to obtain an adequate
sample
D. Lower rate of procedure related birth
defects
E. Less risk of alloimmunization
71. A 37-year-old G3P2 woman presents
with her husband at 11 weeks
gestation for genetic counseling due
to advanced maternal age. The
patient and her husband are
interested in chorionic villus
sampling (CVS). In addition to
obtaining a karyotype, which of the
following can be detected with this
procedure?
C. CVS is generally performed at 10-12 weeks gestation. The procedure involves sampling of
the chorionic frondosum, which contains the most mitotically active villi in the placenta. CVS
can be performed using a transabdominal or transcervical approach. The sampled placental
tissue may be analyzed for fetal chromosomal abnormalities, biochemical, or DNA-based
studies including testing for the mutations associated with cystic fibrosis. CVS cannot be used
to detect neural tube defects. Omphaloceles and neural tube defects are generally
diagnosed using prenatal ultrasound. Both of these conditions are associated with an
increased MSAFP (maternal serum alpha-fetoprotein).

A. Spina bifida
B. Fetal omphalocele
C. Cystic fibrosis
D. Anencephaly
E. Fetal cardiac anomaly
72. A 38-year-old G1P0 woman presents
to the hospital at 39 weeks in early
labor. She has had routine prenatal
care and no antepartum
complications to date. She reports
good fetal movement and denies
vaginal bleeding and leakage of
fluid. What is the next best step in
the initial assessment of this patient?
A. The initial evaluation of patients presenting to the hospital for labor includes a review of
the prenatal records with special focus on the antenatal complications and dating criteria, a
focused history and a targeted physical examination to include maternal vital signs and fetal
heart rate, and abdominal and pelvic examination. A speculum exam with a nitrazine test to
confirm rupture of membranes is indicated if the patient's history suggests this, or if a patient
is uncertain as to whether she has experienced leakage of amniotic fluid. Performing a fetal
ultrasound is not a routine part of an assessment in a patient who may be in early labor. A
prenatal ultrasound may be used in cases to determine fetal presentation, estimated fetal
weight, placental location or amniotic fluid volume.

A. Physical examination
B. Nitrazine test
C. Fetal ultrasound
D. Biophysical profile
E. Contraction stress test
73. A 38-year-old G1P1 woman who C. Signs that a baby is getting sufficient milk include 3-4 stools in 24 hours, six wet diapers in
delivered by a Cesarean delivery 24 hours, weight gain and sounds of swallowing.
three weeks ago presents to the
clinic with concerns that the baby is
not getting enough milk and is fussy.
She reports that she is feeding on
demand and not supplementing.
Which of the following is indicative
that the baby is getting adequate
milk?

A. Sleeps through the night

B. Spits up a small amount of milk
after feeding
C. 3-4 stools in 24 hours
D. 3-4 diapers wet with urine in 24
hours
E. Coverage of the entire areola with
his mouth when he breastfeeds
74. A 39-year-old G1P0 woman presents in labor at term. The
estimated fetal weight is 3200 g. She is 10 cm dilated with
left sacrum anterior at +2 station. Which of the following is
the most appropriate next step in the management of this
patient?
A. Attempt external version
B. Attempt internal version
C. Apply forceps
D. Apply a vacuum
E. Recommend a Cesarean section
75. A 40-year-old G1 woman comes in for her first prenatal
visit. This is an unplanned pregnancy and she had a
positive urine pregnancy test a week ago. She is 16 weeks
gestation based on her last menstrual period. She elects
to have screening for aneuploidy and open neural tube
defects. Her cell-free DNA test returns screen negative.
Her maternal serum alpha-fetoprotein (MSAFP) is
increased (2.6 MoM). What is the most likely explanation
for the elevated MSAFP in this patient?
A. Under-estimation of gestational age
B. Over-estimation of gestational age
C. Twins
D. Neural tube defect
E. Fetal demise
76. A 42-year-old G5P4 woman at eight weeks gestation
presents for her first prenatal appointment. She has
glycosuria noted on urine dipstick in the office. She has a
history of four prior vaginal deliveries at full-term with
birth weights ranging from 9 to 10.5 pounds. Family history
is positive for type 2 diabetes in her mother and two
siblings. Weight is 265 pounds and height is 5 feet 4 inches
(BMI is 45.5 kg/m2). Which of the following
recommendations concerning weight gain during this
pregnancy is most appropriate?
A. Maintain current weight
B. Gain 11 - 20 pounds
C. Gain 15 - 25 pounds
D. Gain 25 - 35 pounds
E. Gain 28 - 40 pounds
77. A 42-year-old G5P4 woman is exclusively breastfeeding
her two-month-old baby when she develops a fever and a
red tender wedge-shaped area on the outer quadrant of
her left breast. Which of the following is the most
appropriate treatment for this condition?
A. Cessation of breastfeeding for 48 hours
B. Cessation of breastfeeding until afebrile
C. Antibiotics
D. Warm compresses
E. Incision and drainage
E. Most recent data suggests that breech infants delivered vaginally
are at higher risk for neonatal complications. Therefore, it would be
recommended that this patient undergo a Cesarean section, especially
since this is her first pregnancy. External cephalic version and internal
versions are contraindicated in active labor. Forceps are used in breech
deliveries to assist in flexion of the head and vacuum applications on
breech presentations are contraindicated.
A. Ninety to ninety-five percent of cases of elevated MSAFP are
caused by conditions other than neural tube defects including under-
estimation of gestational age, fetal demise, multiple gestation, ventral
wall defects and a tumor or liver disease in the patient. Incorrect
dating, specifically under-estimation of gestational age, is the most
common explanation for an elevated MSAFP. The next appropriate
step in the management of this patient is to obtain an ultrasound to
assess the gestational age, viability, rule out multiple gestation as well
as a fetal structural abnormality.
B. The Institute of Medicine (IOM) has developed guidelines (2009) on
weight gain in pregnancy. Historical data show that women who gained
within the IOM guidelines experienced better outcomes of pregnancy
than those who did not. The recommendations are: underweight (BMI <
18.5 kg/m2) total weight gain 28 - 40 pounds; normal weight (BMI 18.5 -
24.9 kg/m2) total weight gain 25 - 35 pounds; overweight (BMI 25 -
29.9 kg/m2) total weight gain 15 - 25 pounds; and obese (BMI > 30
kg/m2) total weight gain 11 - 20 pounds.
C. The patient has a classic picture of mastitis that is usually caused by
streptococcus bacteria from the baby's mouth. Mastitis is easily treated
with antibiotics. The initial choice of antimicrobial is influenced by the
current experience with staphylococcal infections at the institution.
Most are community-acquired organisms, and even staphylococcal
infections are usually sensitive to penicillin or a cephalosporin. If the
infection persists, an abscess may ensue which would require incision
and drainage. However, this patient's presentation is that of simple
mastitis. There is no need for the mother to stop breastfeeding
because of the mastitis.
78. A 45-year-old G2P2 woman presents for a six-week
postpartum check. She reports crying spells, loss of
appetite, difficulty sleeping and a feeling of low
self-worth that began one week after her delivery.
She denies any suicidal or homicidal ideations. She
is frustrated because she has not been able to
breastfeed and feels that she is a bad mother. She
has a previous history of anxiety. Which of the
following is the most likely diagnosis in this patient?
C. Postpartum depression is a common condition estimated to affect
approximately 10-15% of women and often begins within two weeks to six
months after delivery. Signs and symptoms of depression which last for less
than two weeks are called postpartum blues; it occurs in 40-85% of women in
the immediate postpartum period. It is a mild disorder that is usually self-
limited. This patient does not have signs/symptoms of anxiety disorder or
bipolar disorder.

A. Normal puerperium
B. Postpartum blues
C. Postpartum depression
D. Anxiety disorder
E. Bipolar disorder
79. An African-American couple comes to you for D. Screening for carriers of both alpha and beta thalassemia is possible by
preconception counseling. Neither one has any evaluation of red cell indices. Although solubility tests for hemoglobin S or
significant family or genetic history. Based on their sickle cell preparations can be used for screening, hemoglobin
African-American descent, which of the following electrophoresis is definitive and preferable because other
blood tests would you recommend? hemoglobinopathies can also be detected including hemoglobin C trait and
thalassemia minor. Although sickle cells can be identified on a blood smear in
A. MCV and CBC individuals with sickle cell disease, the cells may be absent in individuals with
B. Sickle cell preparation and CBC milder types of sickle cell disease and even in some individuals with severe
C. Peripheral blood smear and CBC sickle cell disease. Evaluation of a peripheral smear is not useful in detecting
D. Hemoglobin electrophoresis and CBC carriers for sickle cell disease.
E. Sickle cell preparation with a hemoglobin
electrophoresis, if the sickle preparation is
abnormal
80. At one minute of life, an infant has a heart rate E. Heart rate= 2, Respiratory rate= 2, Reflex = 2, Activity =2, Color =1. Therefore,
greater than 120 beats/minute, is crying, has the one-minute APGAR score is 9.
acrocyanosis, gags when suctioned and is
vigorously moving all four extremities. What is the
APGAR score for this infant?

A. 5
B. 6
C. 7
D. 8
E. 9
 Unit 2: Obstetrics - B. Abnormal Obstetrics
Study online at quizlet.com/_2iif08
1. A 16-year-old G1P0 African-American female presents at
eight weeks gestation for prenatal care. She reports
occasional spotting but denies pain or fever. The
laboratory reports hemoglobin of 8 g/dL and a peripheral
smear reveals hypochromia and microcytosis. Which of the
following is the most likely diagnosis for this patient?
A. Sickle cell anemia
B. Folate deficiency
C. Iron deficiency
D. -thalassemia
E. Acute blood loss
2. A 17-year-old G1P0 female at 39 weeks gestation presents
with increased swelling in her face and hands over the last
two days. Her blood pressure is 155/99. She has 2 plus
pitting edema of the lower extremities. A 24-hour urine
collection shows 440 mg of protein. What is the next best
step in the management of this patient?
A. Fluid restriction
B. Magnesium sulfate
C. Furosemide
D. Hydralazine
E. Delivery
3. A 17-year-old G1 woman at 24 weeks gestation presents
with vaginal bleeding. She denies any pain, cramping or
dysuria. She reports last having intercourse three weeks
ago. Prenatal care and labs have been unremarkable. Her
vital signs are normal and she is afebrile. Pelvic ultrasound
reveals a fundal placenta and viable fetus. Abdominal
examination is unremarkable. Vaginal examination reveals a
uniformly friable cervix with a small amount of blood in the
vault. Digital examination reveals a firm, closed cervix.
What is the most likely diagnosis that explains the
bleeding?
A. Trauma
B. Cervical cancer
C. Cervicitis
D. Bloody show
E. Threatened abortion
C. The two most common causes of anemia during pregnancy and the
puerperium are iron deficiency and acute blood loss. Classical
morphological evidence of iron-deficiency anemia includes
erythrocyte hypochromia and microcytosis. Serum ferritin levels are
lower than normal and there is no stainable bone marrow iron on
examination of a bone marrow aspirate. The spotting she reports
would not lead to anemia due to blood loss
E. Regardless of disease severity, the only definitive therapy for
preeclampsia is delivery of the fetus and placenta. This solution can
occasionally be delayed in the setting of stable disease (mild or
severe) when it occurs at an extremely early gestational age. Fluid
management must be monitored closely in this person. Magnesium
sulfate is the mainstay of therapy during labor and for 24 hours
postpartum to lower the seizure threshold in women with severe
disease. Low-dose aspirin may have some benefit in decreasing the risk
of preeclampsia in a subset of high-risk patients. Hydralazine is often
the antihypertensive agent of choice for controlling elevated blood
pressures in the acute setting.
C. Cervicitis caused by chlamydia, gonorrhea, trichomonas or other
infections can present with vaginal bleeding. The cervix is much more
vascular during pregnancy and inflammation can lead to bleeding.
Evaluation for other causes of bleeding must be completed and then
treatment for the infection should be initiated. The patient does not
give any history of trauma and cancer is unlikely because of her age.
She is not in labor, and a bloody show associated with cervical
dilatation is not consistent with the history provided. Threatened
abortion occurs during the first trimester.
4. A 17-year-old G2P0 female has severe right lower quadrant pain. Her last
normal menstrual period was seven weeks ago. She notes that last night she
began having suprapubic pain that radiated to her right lower quadrant. This
morning, the pain awoke her from sleep. She has had no vaginal bleeding, no
nausea or vomiting. The patient's history is notable for two first trimester
elective abortions and a history of chlamydia treated twice. Vital signs are
blood pressure 90/60; pulse 99; respirations 22; and temperature 98.6F
(37C). On physical exam, the patient is noted to be curled on a stretcher in a
fetal position and says she hurts too much to move. She has rebound and
voluntary guarding on abdominal examination. She has severe cervical motion
tenderness and rectal tenderness. Her Beta-hCG level is 2500 mIU/ml;
hematocrit 24%; and urinalysis negative. Ultrasound shows no intrauterine
pregnancy, a right adnexal mass that measures 6 x 2 cm, and a moderate
amount of free fluid in the cul de sac. Which of the following is the most
appropriate next step in the management of this patient?
A. Admit for serial examinations
B. Exploratory surgery
C. Recheck Beta-hCG level in 48 hours
D. Administer methotrexate
E. Dilation and curettage
5. An 18-year-old G1P0 woman presents at 32 weeks for a routine visit. She
complains of intense itching for the past two weeks and cannot stop scratching
her arms, legs, and soles of her feet. She has tried over the counter lotions
and antihistamines with no relief. She also states that her family noticed she is
slightly yellow. Her vital signs are normal and there are scattered excoriations
over her arms and legs. Which of the following is the best treatment in the
management of this patient?
A. Aggressive hydration
B. Antivirals such as Acyclovir
C. Antihistamines
D. Ursodeoxycholic acid
E. Steroids
6. An 18-year-old G1 woman at 32 weeks gestation presents with severe
abdominal pain and a small amount of bleeding. She has received routine
prenatal care, smokes one pack of cigarettes per day and admits to using
crack cocaine. On exam, her blood pressure is 140/80; pulse 100; and she is
afebrile. Her uterus is tense and very tender. Pelvic ultrasound reveals a
fundal placenta, cephalic presentation of the fetus and no other abnormalities.
Cervical examination reveals blood coming through the os and is one
centimeter dilated. Fetal heart tones have a baseline of 160s, with a category
III tracing. Which of the following is the most likely diagnosis?
A. Placenta previa
B. Premature rupture of the membranes
C. Preterm labor
D. Placental abruption
E. Chorioamnionitis
B. This patient has a ruptured ectopic pregnancy
until proven otherwise. Her vital signs, examination
and anemia are consistent with an intra-abdominal
bleed. Exploratory laparoscopy/laparotomy is
indicated at this point. Conservative management
with observation, serial examinations or repeat
Beta-hCG testing could be dangerous in a patient
suspected of having a ruptured ectopic pregnancy.
Medical management (methotrexate) is not used in
a patient with an acute surgical abdomen. Dilation
and curettage would not be the next step in
management and might only be considered in this
scenario after the patient's abdomen was explored.
D. This patient has pruritus gravidarum, a common
pregnancy-related skin condition that is a mild
variant of intrahepatic cholestasis of pregnancy.
There is retention of bile salt, and as serum levels
increase they are deposited in the dermis. This, in
turn, causes pruritus. The skin lesions are
secondary to scratching and excoriation.
Antihistamines and topical emollients may provide
some relief and should be used initially.
Ursodeoxycholic acid relieves pruritus and lowers
serum enzyme levels. Another agent reported to
relieve the itching is the opioid antagonist
naltrexon. Hydroxychloroquine is used to treat
lupus and is not indicated in this patient.
D. This patient has a placental abruption. Common
presenting signs of an abruption include
abdominal pain, bleeding, uterine hypertonus and
fetal distress. Risk factors include smoking, cocaine
use, chronic hypertension, trauma, prolonged
premature rupture of membranes, and history of
prior abruption. Treatment would involve an
emergent Cesarean delivery with appropriate
resuscitation, including intravenous fluids and
blood products as needed. A placenta previa is an
abnormal location of the placenta.
Chorioamnionitis is an infection that typically
occurs following prolonged rupture of
membranes, and is frequently accompanied by a
maternal fever. Premature rupture of membranes
presents with loss of fluid not active bleeding.
7. An 18-year-old G1 woman presents for prenatal care at
16 weeks gestation without complaints. The patient
denies any history of sexually transmitted disease,
although admits to a history of multiple sex partners,
with irregular use of condoms. She is allergic to
penicillin, which causes anaphylaxis. Physical exam is
unremarkable. Pertinent labs: rapid plasma reagin test
(RPR) positive (titer = 32); fluorescent treponemal
antibody absorption test (FTA-ABS) is positive. Which
of the following is the best treatment for this patient?
A. Oral erythromycin
B. Oral doxycycline
C. Desensitization and penicillin
D. Intravenous erythromycin
E. Intravenous cefazolin
8. A 19-year-old G1P0 woman at 18 weeks gestation
presents with a three-month history of palpitations and
intermittent chest pain. Physical examination reveals a
pulse of 96 and grade II/VI systolic ejection murmur
with a click. The ECG shows normal rate and rhythm
and an echocardiogram is ordered. Which of the
following is the best treatment in the management of
this patient?
A. Anxiolytics
B. -blockers
C. Calcium-channel blockers
D. Digitalis
E. No treatment needed at this time
9. A 19-year-old G1P0 woman at 28 weeks gestation
comes to labor and delivery because of the onset of
contractions. The patient describes the contractions as
progressively becoming more painful, each lasting 40
seconds and now occurring every five minutes. She
reports good fetal movement and does not have any
bleeding or leakage of fluid. On evaluation in triage, it
is noted that she is having regular contractions,
approximately every five minutes, has intact
membranes and her cervical exam is 3 cm dilated and
50% effaced. What is the most frequent cause of this
condition?
A. Dehydration
B. Fetal anomalies
C. Idiopathic
D. Uterine fibroids
E. Cervical incompetence
C. This patient has syphilis, and the fluorescent treponemal antibody
absorption test (FTA-ABS) confirms the diagnosis. The transmission rates
for primary and secondary disease are approximately 50-80%. There are
no proven alternatives to penicillin therapy during pregnancy and penicillin
G is the therapy of choice to treat syphilis in pregnancy. Women with a
history of penicillin allergy can be skin tested to confirm the risk of
immunoglobulin E (IgE)-mediated anaphylaxis. If skin tests are reactive,
penicillin desensitization is recommended and is followed by intramuscular
benzathine penicillin G treatment. Erythromycin has an 11% failure rate.
Doxycycline is contraindicated in pregnancy. Cefazolin is commonly used
to treat urinary tract infections and is not effective in the treatment of
syphillis.
B. This patient has classic symptoms of mitral valve prolapse. Most women
with mitral valve prolapse are asymptomatic and diagnosed by routine
physical examination or as an incidental finding at echocardiography. A
small percentage of women with symptoms have anxiety, palpitations,
atypical chest pain, and syncope. For women who are symptomatic, b-
blocking drugs are given to decrease sympathetic tone, relieve chest pain
and palpitations, and reduce the risk of life-threatening arrhythmias.
Because she is symptomatic, the option of no treatment is not correct.
C. In most cases, preterm labor is idiopathic (i.e. no cause can be
identified). Dehydration and uterine distortion (from uterine fibroids or
structural malformations) can be associated with preterm labor. In some
cases, preterm labor is due to iatrogenic causes; for example, when a
physician induces a preterm patient who has severe preeclampsia. Fetal
anomalies typically do not cause preterm labor. Cervical incompetence is
usually diagnosed earlier in the second trimester and is associated with
painless cervical dilation.
10. A 19-year-old G1P0 woman at 39 weeks gestation presents in labor. A. Variable decelerations are reflex mediated usually
She denies ruptured membranes. Her prenatal course was associated with umbilical cord compression as a result of
uncomplicated and ultrasound at 18 weeks revealed no fetal cord wrapped around fetal parts, fetal anomalies or
abnormalities. Her vital signs are: blood pressure 120/70; pulse 72; oligohydramnios. The presence of light meconium-stained
temperature 101.0 F (38.3 C); fundal height 36 cm; and estimated fluid is not associated with a specific fetal heart rate tracing.
fetal weight of 2900 gm. Cervix is dilated to 4 cm, 100% effaced and Uteroplacental insufficiency is associated with late
at +1 station. She receives 10 mg of morphine intramuscularly for pain decelerations. Maternal drugs may cause loss of variability.
and soon after has spontaneous rupture of the membranes. Light
meconium-stained fluid was noted and, five minutes later, the fetal
heart rate tracing revealed variable decelerations with moderate
variability. What is the most likely cause for the variable
decelerations?

A. Umbilical cord compression

B. Meconium
C. Maternal fever
D. Uteroplacental insufficiency
E. Morphine administration
11. A 19-year-old G1P0 woman at 40 weeks gestation has an C. Methergine, prostaglandins and oxytocin are all
uncomplicated vaginal delivery followed by a brisk hemorrhage. Her uterotonics and used to increase uterine contractions and
past medical history is significant for steroid-dependent asthma. Her decrease uterine bleeding. Prostaglandin F2-alpha
blood pressure is 110/70; pulse 84; and she is afebrile. Which of the (Hemabate) is a potent smooth muscle constrictor, which
following uterotonic agents should not be used in this patient? also has a bronchio-constrictive effect. As such, it should
be used with caution in any patient with a reported history
A. Intramuscular oxytocin of asthma. It is absolutely contraindicated in patients with
B. Intravenous oxytocin poorly controlled or severe asthma. Prostaglandin E1
C. Prostaglandin F2-alpha (Misoprostol), often used for cervical ripening and labor
D. Prostaglandin E1 (Misoprostol) induction, is frequently used in oral or rectal suppository
E. Methylergonovine form for treatment of uterine atony, although not FDA
approved for this use.
12. A 19-year-old G1P0 woman at 41
weeks with spontaneous rupture of
membranes for 13 hours presented
to labor and delivery. She had an
uncomplicated prenatal course.
Her vital signs are: blood pressure
120/70; pulse 72; afebrile; fundal
height 36 cm; and estimated fetal
weight of 2700 gm. Cervix is
dilated to 4 cm, 100% effaced, + 1
station. What does the fetal heart
rate tracing seen below show?
(fetal heart rate trough min prior to
max of CTX)
A. Late deceleration
B. Variable decelerations
C. Early decelerations
D. Sinusoidal rhythm
E. Normal fetal heart rate pattern
13. A 19-year-old G1P0 woman at 42
weeks gestation presents to labor
and delivery with spontaneous
rupture of membranes for 13 hours
and spontaneous onset of labor.
Her vital signs are: blood pressure
120/70; pulse 72; afebrile; fundal
height 36 cm; and estimated fetal
weight of 2700 gm. Cervix is
dilated to 4 cm, 100% effaced, +1
station. Which statement best
describes the tracing seen below?
(fetal heart rate baseline 130s with
high moderate variability and
decels. no relationship to CTX)
A. Normal fetal heart rate pattern
B. Sinusoidal rhythm
C. Late deceleration
D. Variable deceleration
E. Early deceleration
C. Early decelerations are physiologic caused by fetal head compression during uterine
contractions, resulting in vagal stimulation and slowing of the heart rate. This type of
deceleration has a uniform shape, with a slow onset that coincides with the start of the
contraction and a slow return to the baseline that coincides with the end of the contraction.
Thus, it has the characteristic mirror image of the contraction. A late deceleration is a symmetric
fall in the fetal heart rate, beginning at or after the peak of the uterine contraction and
returning to baseline only after the contraction has ended. Late decelerations are associated
with uteroplacental insufficiency. Variable decelerations show an acute fall in the FHR with a
rapid down slope and a variable recovery phase. They are characteristically variable in
duration, intensity, and timing, and may not bear a constant relationship to uterine contractions.
The true sinusoidal pattern is a regular, smooth, undulating form typical of a sine wave that
occurs with a frequency of two to five cycles/minute and an amplitude range of five to 15 beats
per minute. It is also characterized by a stable baseline heart rate of 120 to 160 beats per minute
and absent beat-to-beat variability.
D. Variable decelerations show an acute fall in the FHR, with a rapid down slope and a variable
recovery phase. They are characteristically variable in duration, intensity, and timing, and may
not bear a constant relationship to uterine contractions. They are typically associated with cord
compression, especially in the setting of low amniotic fluid volume. Early decelerations are
physiologic caused by fetal head compression during uterine contraction, resulting in vagal
stimulation and slowing of the heart rate. This type of deceleration has a uniform shape, with a
slow onset that coincides with the start of the contraction and a slow return to the baseline that
coincides with the end of the contraction. Thus, it has the characteristic mirror image of the
contraction. A late deceleration is a symmetric fall in the fetal heart rate, beginning at or after
the peak of the uterine contraction and returning to baseline only after the contraction has
ended. Late decelerations are associated with uteroplacental insufficiency. The true sinusoidal
pattern is a regular, smooth, undulating form typical of a sine wave that occurs with a frequency
of two to five cycles/minute and an amplitude range of five to 15 beats per minute. It is also
characterized by a stable baseline heart rate of 120 to 160 beats per minute and absent beat-
to-beat variability.
14. A 19-year-old G1P0 woman notes vaginal spotting. Her last normal
menstrual period occurred six weeks ago. She began having
spotting early this morning and it has increased only slightly. She
has no pain and denies other symptoms. Her medical history is
noncontributory. Vital signs are: blood pressure 120/68; pulse 68;
respirations 20; and temperature 98.6F (37.0C). On pelvic exam,
her cervix is normal; uterus is small and nontender; and no masses
are palpable. Initial labs show quantitative Beta-hCG 2000 mIU/ml
and hematocrit 38%. A repeat Beta-hCG level 48 hours later is 2100
mIU/ml. A transvaginal ultrasound shows an empty uterus with a
thin endometrial stripe and no adnexal masses. What is the next
best step in the management of this patient?
B. The patient clearly has an abnormal pregnancy, as
demonstrated by the slowly increasing Beta-hCG levels. Since
the Beta-hCG level is above 2000 mIU/ml, and she has a thin
endometrial stripe, this excludes an intrauterine pregnancy
and the diagnosis is an ectopic pregnancy. She is a good
candidate for medical treatment with methotrexate. Criteria to
consider for medical treatment include hemodynamic stability,
non-ruptured ectopic pregnancy, and size of ectopic mass.

A. Dilation and curettage

B. Treat with methotrexate
C. Exploratory laparotomy
D. Repeat Beta-hCG level in 48 hours
E. . Repeat ultrasound in 24 hours
15. A 19-year-old G1P0 woman presents in labor at term. Her prenatal A. Postpartum hemorrhage is defined as bleeding in excess of
course was uncomplicated. She delivers a 3500 gram infant 500 cc after a vaginal delivery or in excess of 1000 cc after a
spontaneously after oxytocin augmentation of labor. Postpartum, Cesarean delivery.
she experiences excessive bleeding. Which of the following
defines postpartum hemorrhage in this patient?

A. Greater than 500 cc

B. Greater than 750 cc
C. Greater than 1000 cc
D. Greater than 1500 cc
E. Any amount of bleeding that leads to hypovolemia
16. A 19-year-old G1P0 woman with a desired pregnancy notes vaginal
spotting early this morning and it has slightly increased. Her last
normal menstrual period occurred six weeks ago. She has no pain
or other symptoms. Her medical history is noncontributory. Vital
signs are: blood pressure 120/68; pulse 68; respirations 20; and
temperature 98.6F (37.0C). On pelvic exam, her cervix is normal;
her uterus is small and nontender; there are no masses palpable.
Labs show: quantitative Beta-hCG 750 mIU/ml; progesterone 3.8
ng/ml; hematocrit 38%. Which of the following is the most
appropriate next step in the management of this patient?
A. Order a transvaginal ultrasound
B. Repeat Beta-hCG level in 24 hours
C. Repeat Beta-hCG level in 48 hours
D. Dilation and curettage
E. Bed rest
C. Repeating the Beta-hCG level will show whether the
pregnancy is viable or failing. The appropriate time interval for
repeating the initial level is 48 hours, since during the first 42
days of gestation levels increase by approximately 50% every
48 hours in most viable pregnancies. Ordering an ultrasound
would not be helpful, since the patient's Beta-hCG level is
lower than the discriminatory zone (the level at which an
intrauterine pregnancy should be seen on ultrasound, usually
2000 mIU/ml). There is no need to repeat the progesterone
level. Dilation and curettage or treatment with methotrexate
are both inappropriate without a diagnosis, since both could
interrupt a viable pregnancy. Bedrest is not indicated in this
patient.
17. 19-year-old G1 woman at 36 weeks gestation presents for her first
prenatal visit, stating she was recently diagnosed with HIV after her
former partner tested positive. The HIV Western Blot is positive. The
CD4 count is 612 cells/l. The viral load is 9,873 viral particles per ml of
patient serum. Which of the management options would best decrease
the risk for perinatal transmission of HIV?
A. Treatment with intravenous zidovudine at the time of delivery
B. Treatment of the newborn with oral zidovudine only if HIV-positive
C. One week maternal treatment with zidovudine now
D. Cesarean section in second stage of labor
E. Single drug therapy to minimize drug resistance
18. 19-year-old G1 woman presents at 28 weeks gestation for prenatal
care. Her past medical history is unremarkable except for a
splenectomy following a motor vehicle accident four years ago.
Prenatal labs today show a hemoglobin of 12 g/dL; blood type O
positive; Rh negative with antibody screen positive for Lewis (titer 1:16).
What is the next best step in the management of this pregnancy?
A. Check father of the baby's antibody status
B. Biophysical profile
C. Serial amniocentesis
D. Percutaneous umbilical blood sampling
E. Reassurance
19. A 19-year-old G2P1 African American woman at 30 weeks gestation
presents with preterm rupture of membranes six hours ago. Her
prenatal course has been complicated by two episodes of bacterial
vaginosis for which she was treated. She takes prenatal vitamins and
iron. She denies substance abuse or alcohol use, but admits to smoking
five cigarettes each day. Her prior pregnancy was delivered vaginally
at 41 weeks after spontaneous rupture of membranes. Her blood
pressure is 110/70; pulse 84; temperature 98.6F (37.0C). Pertinent
sonographic findings reveal oligohydramnios and a cervical length of
30 mm. Which of the following is the most likely cause of preterm
premature rupture of membranes in this patient?
A. Ethnicity
B. Smoking
C. Previous premature rupture of membranes
D. Cervical length
E. Genital tract infections
20. A 19-year-old G2P1 woman at 28 weeks gestation has been diagnosed
with preterm labor. Her physician has chosen to treat her with
magnesium sulfate. By what mechanism of action does magnesium
sulfate work as a tocolytic?
A. Decreases prostaglandin (PG) production
B. Competes with calcium for entry into cells
C. Increases cAMP in the cell
D. Blocks calcium entry into muscle cells
E. Inhibits calcium transport
A. Antiretroviral therapy should be offered to all HIV-
infected pregnant women to begin maternal treatment as
well as to reduce the risk of perinatal transmission
regardless of CD4+ T-cell count or HIV RNA level. The
baseline transmission rate of HIV to newborns can be
reduced from about 25% to 2% with the HAART (highly
active antiretroviral therapy) protocol antepartum and
continuing through delivery with intravenous zidovudine
in labor and zidovudine treatment for the neonate.
Cesarean section prior to labor can reduce this rate to 2%
(although the benefit is less clear in women with viral
loads).
E. The patient should be reassured that the fetus is not at
risk even though the antibody titer is 1:16. Lewis antibodies
are IgM antibodies and do not cross the placenta,
therefore are not associated with isosensitization or
hemolytic disease of the fetus. The father of the baby
does not need to be tested nor does this unaffected fetus
need a biophysical profile. The other tests listed above
are invasive and used to monitor fetuses at risk for
anemia, hydrops and fetal death.
E. The primary risk factor for preterm rupture of
membranes is genital tract infection, especially associated
with bacterial vaginosis. All of the other listed options are
risk factors. Smoking and prior preterm premature rupture
of membranes (which she did not have previously
because she delivered at 41 weeks) increases the
likelihood of preterm rupture of membranes two-fold. A
shortened cervical length is also a risk factor, but her
cervical length is normal.
B. Magnesium sulfate works by competing with calcium
entry into cells. Beta-adrenergic agents work by
increasing cAMP in the cell, thereby decreasing free
calcium. Prostaglandin synthetase inhibitors, such as
Indomethacin, work by decreasing prostaglandin (PG)
production by blocking conversion of free arachidonic
acid to PG. Calcium channel blockers prevent calcium
entry into muscle cells by inhibiting calcium transport.
21. A 19-year-old G2P1 woman presents with vaginal spotting and uterine
cramping. Her last normal menstrual period was six weeks ago and she
began spotting three days ago. She has no history of sexually
transmitted infections. Her vital signs are blood pressure 120/70; pulse
78; respirations 20; and temperature 98.6F (37.0C). On pelvic
examination, she has no cervical motion tenderness, her uterus is
normal size and non-tender; no adnexal masses are palpable.
Quantitative Beta-hCG 48 hours ago was 1500 mIU/ml. Currently, Beta-
hCG is 3100 mIU/ml. Progesterone is 26 ng/ml; hematocrit is 38%; and
urinalysis is normal. What is the most likely finding on transvaginal
ultrasound?
B. Transvaginal ultrasound will most likely show an
intrauterine pregnancy. The Beta-hCG level is above the
discriminatory zone for ultrasound (2000 mIU/ml), and
the level has doubled in 48 hours. Additionally, the
progesterone level is within expected range for a normal
pregnancy (>25 ng/ml suggests healthy pregnancy) and
up to 30% of all normal pregnancies experience first
trimester spotting/bleeding. The findings of debris in the
uterus, an empty uterus, with or without an adnexal mass,
or free fluid (suggesting hemoperitoneum) would not be
anticipated.

A. Debris in uterus
B. Viable intrauterine pregnancy
C. Adnexal mass, empty uterus
D. No adnexal mass, empty uterus
E. Non-viable intrauterine pregnancy
22. A 19-year-old G3P0 woman at 39 weeks gestation with spontaneous D. The baseline fetal heart rate is >160 with no
rupture of membranes for 13 hours presented to labor and delivery. accelerations or variability. There are regular
Her vital signs are: blood pressure 120/70; pulse 72; afebrile; fundal contractions. Prolonged periods of fetal tachycardia are
height 36 cm; and estimated fetal weight of 2700 gm. Cervix is dilated frequently found with maternal fever or chorioamnionitis.
to 1 cm, 50% effaced, -2 station. Which statement best describes the
tracing seen below?
(fetal baseline in 170s, flattish line til end then irregular decel; CTX
regular)

A. Normal fetal heart rate with good variability and regular

contractions
B. Fetal tachycardia with good variability and regular contractions
C. Normal fetal heart rate with poor variability and irregular
contractions
D. Fetal tachycardia with poor variability and regular contractions
E. Normal fetal heart rate with good variability and irregular
contractions
23. A 20-year-old G0 woman presents for prenatal care at 10 weeks E. This patient has alpha thalassemia trait characterized
gestation. She states that she is healthy and denies vaginally bleeding. by mild anemia, macrocytic and hypochromic anemia and
Prenatal labs reveal a hemoglobin of 9.1 g/dL with the following indices: a normal hemoglobin electrophoresis. She denies blood
loss therefore acute blood loss is unlikely and her serum
MCV (mean cellular volume): 72 femtoliter ferritin is normal ruling out iron deficiency anemia.
MCH (mean cellular hemoglobin): 22 picograms/cell Hemoglobin H disease and beta thalassemia are
Serum ferritin: 108 mcq/L characterized by moderate to severe anemia. Beta-
Hemoglobin A2: normal thalassemia would have hemoglobin F as well as
Hemoglobin F: normal hemoglobin A2 on hemoglobin electrophoresis.
Hemoglobin electrophoresis: normal

What is the most likely cause of anemia in this patient?

A. Acute blood loss

B. Iron deficiency anemia
C. Hemoglobin H disease
D. Beta thalassemia
E. Alpha thalassemia trait
24. A 20-year-old G1P0 woman has vaginal spotting and mild
cramping for the last three days. Her last normal menstrual
period was approximately seven weeks ago. She had a
positive home pregnancy test. Vital signs are: blood pressure
120/72; pulse 64; respirations 18; temperature 98.6F (37C).
On pelvic exam, she has scant old blood in the vagina, with a
normal appearing cervix and no discharge. On bimanual
exam, her uterus is nontender and small, and there are no
adnexal masses palpable. Quantitative Beta-hCG 48 hours
ago was 750 mIU/ml. Today, current Beta-hCG 760 mIU/ml;
progesterone 3.2 ng/ml; hematocrit 37%. Transvaginal
ultrasound shows a fluid collection in the uterus with a yolk
sac but no fetal pole. A 3x3 cm cyst is seen on the left ovary.
There is no free fluid in the pelvis. Which of the following is
the most appropriate next step in the management of this
patient?
D. The pregnancy is abnormal based on the abnormal Beta-hCG
levels and the progesterone level. In a normal pregnancy, the level
should rise by at least 50% every 48 hours until the pregnancy is 42
days old (after that time, the rise in level may not follow the
projection curve). A progesterone level of <5 ng/ml suggests an
abnormal or extrauterine pregnancy. In this instance, the
pregnancy is intrauterine because of the presence of a yolk sac.
Expectant management is appropriate and may avoid the risks of
surgery. Other options include misoprostol, manual vacuum
aspiration, or dilation and curettage. Laparoscopy and
methotrexate are not indicated as this is a confirmed intrauterine
pregnancy. Mifepristone is a progestin receptor antagonist and can
be used as emergency contraception to prevent ovulation and
blocks the action of progesterone which is needed to maintain
pregnancy. In the US, Mifepristone is also used with misoprostol for
pregnancy termination.

A. Exploratory laparoscopy
B. Treat with methotrexate
C. Treat with mifepristone
D. Expectant management
E. Repeat ultrasound in one week
25. A 20-year-old G1P1 woman delivered her first baby 24 hours C.
ago. Delivery was uncomplicated and she had an epidural
placed for analgesia at 5 cm of cervical dilation. Earlier in the Likely meningitis, perhaps from the epidural.
afternoon, she was complaining of a headache and was given
ibuprofen. Three hours later, she complained of increasing
headache, photophobia and nausea. She denies heavy
bleeding. Vital signs are pulse 110; respirations 20;
temperature 101.5 F (38.6 C); and blood pressure 100/50.
Physical examination reveals obvious distress, as she has her
eyes covered and pain when she moves her neck. Her lungs
are clear and heart has a regular rate. Her abdomen is
nontender, and uterine fundus is easily palpable just below
the umbilicus and is nontender. Her extremities reveal no
erythema, swelling or tenderness. Which of the following
would most helpful to establish a diagnosis in this patient?
A. Chest x-ray
B. Urinalysis
C. Lumbar puncture
D. CBC with differential
E. Pelvic ultrasound
26. A 20-year-old G1 woman at 40 weeks gestation presents to labor
and delivery complaining of painful contractions every 3-4
minutes for the last eight hours. Cervical examination on
admission was 2 centimeters dilated, 90% effaced and 0 station.
Three hours later, her exam is unchanged. The patient is still
having contractions every 3-4 minutes. She is discouraged about
her lack of progress. Which of the following is the most
appropriate next step in the management of this patient?
A. Laminaria placement
B. Artificial rupture of membranes
C. Counseling about latent phase of labor and rest
D. Manual cervical dilation
E. Cesarean section for arrest of labor
27. A 20-year-old G2P1 woman at 28 weeks gestation presents to
labor and delivery with contractions every four minutes. On
physical examination, her vital signs are: temperature 101F
(38.3C); heart rate 120; respiratory rate 18; and blood pressure
110/65. Her uterine fundus is tender and the rest of the physical
exam is normal. Her cervix is dilated 1 cm and is 50% effaced. The
fetus is in vertex presentation. Fetal heart tones are in the 150s
with a Category I tracing. Her white blood cell count (WBC) is
18,000/mcL. Which of the following is the most appropriate next
step in the management of this patient?
A. Observation
B. Tocolysis
C. Contraction stress test
D. Labor induction
E. Cesarean section
28. A 20-year-old G2P1 woman is at 41 weeks gestation. Her prenatal
course and past medical history are unremarkable. She has not
had any complications with her pregnancy and fetal surveillance
is reassuring. Which of the following complications is most likely
to occur in this pregnancy?
A. Preeclampsia
B. Retained placenta
C. Postpartum hemorrhage
D. Macrosomia
E. Placenta abruption
C. The patient is in the latent phase of labor and has not yet
reached the active phase (more than 4 cm). A prolonged latent
phase is defined as >20 hours for nulliparas and >14 hours for
multiparas, and may be treated with rest or augmentation of
labor. Artificial rupture of membranes is not recommended in
the latent phase as it places the patient at increased risk of
infection. Cervical dilation or laminaria placement are not
indicated.
D. This patient has a fever, a tender fundus, and elevated white
blood cell count, which are concerning for an intra-amniotic
infection. Delivery is warranted and in the case of reassuring
heart tones, there are no contraindications for labor induction
and a Cesarean section is not indicated at this time. Tocolytics
should not be used in the case of an intra-amniotic infection.
Conservative management with observation would delay
diagnosis and would not be appropriate. A contraction stress
test is not indicated since the patient is already contracting
with reassuring fetal heart tones.
D. Postterm pregnancies are associated with macrosomia,
oligohydramnios, meconium aspiration, uteroplacental
insufficiency and dysmaturity. Although postterm infants are
larger than term infants and have an increased incidence of
fetal macrosomia, there is no evidence to support induction of
labor as a preventive measure for macrosomia in these cases.
There is no associated risk for preeclampsia in postterm
gestations.
29. A 21-year-old G1P0 woman presents to labor and delivery at
39 weeks gestation with a chief complaint of decreased fetal
movement over the last two days. An ultrasound shows a
fetus with biometry consistent with 34 weeks gestation with
no cardiac activity. The head circumference and biparietal
diameter are consistent with 37 weeks and the abdominal
circumference, femur and humerus lengths are all lagging by
approximately five weeks. The amniotic fluid volume is
slightly decreased. No other abnormalities are identified.
The patient's medical history is notable for a deep venous
thrombosis which she had three years ago while she was
using oral contraceptives. She had a reassuring quad screen.
She denies any history of fever or viral illnesses during the
pregnancy. She works as a preschool teacher. The patient
had a fetal ultrasound at 20 weeks gestation. At that time all
of the fetal anatomy was well-visualized and no
abnormalities were identified. Which of the following is the
most likely explanation for the fetal demise in this case?
A. Trisomy 21
B. Trisomy 18
C. Poorly controlled undiagnosed diabetes mellitus
D. Fetal parovirus infection
E. Factor V Leiden mutation
30. A 21-year-old G1 woman at 36 weeks gestation presents with
sudden onset of abdominal pain and bleeding. She smokes a
pack of cigarettes a day, but otherwise her pregnancy has
been uncomplicated. She takes no medications other than
prenatal vitamins. Her blood pressure is 150/90; pulse 90;
and she is afebrile. Her uterus is tense and very tender.
Pelvic ultrasound shows the placenta to be posterior and
fundal, with a cephalic presentation of the fetus. Cervical
examination reveals no lesions, blood coming through the os
and is one centimeter dilated. Fetal heart tones have a
baseline of 150, with a Category III fetal heart rate tracing.
Tocometer reveals contractions every 30-45 seconds. Which
of the following is the most appropriate next step in the
management of this patient?
A. Amniotomy
B. Cesarean delivery
C. Induction of labor
D. Tocolysis
E. A double set-up examination
A. This patient is most likely to have the autosomal dominant Factor
V Leiden (FVL) mutation based on her history. FVL is the most
common inherited thrombophilic disorder affecting approximately
5% of Caucasian women in the United States. It is a point mutation
which alters factor V making it resistant to inactivation by protein C.
The thrombophilic effect of a FVL mutation has been clearly
established. Heterozygosity for FVL is associated with a five- to ten-
fold increased risk of thrombosis, while homozygosity is associated
with an 80-fold increased risk. The FVL mutation is associated with
obstetric complications including stillbirth, preeclampsia, placental
abruption and IUGR. Fetuses with Trisomy 18 are likely to have
congenital anomalies that are detectable on prenatal ultrasound.
Over 90% of cases of trisomy 21 and 18 may be detected with the
quad screen. A congenital parvovirus infection associated with a
fetal demise would likely cause hydrops in the fetus which would be
identified on ultrasound. Although poorly controlled diabetes
mellitus are associated with fetal demise, they are not the most likely
etiologies in this patient whose presentation is classic for the FVL
mutation.
B. This patient is undergoing a placental abruption, with a
deteriorating fetal condition. An emergent Cesarean delivery is
necessary. The mother risks excessive blood loss, DIC and possible
hysterectomy. The fetus risks neurological injury from anoxia or
death. Risk factors for abruption include smoking, cocaine use,
abdominal trauma, chronic hypertension, multiparity and prolonged
premature rupture of membranes. Since immediate delivery is
needed, amniotomy, induction, or tocolysis are not appropriate. A
double set-up examination (performed in the operating room with a
Cesarean section team scrubbed and ready) is not indicated, since
the ultrasound determined the location of the placenta to be fundal.
31. A 22-year-old G1P0 woman at 39-weeks gestation B. Prematurity, multiple gestation, genetic disorders, polyhydramnios,
presents in active labor. Her pregnancy is hydrocephaly, anencephaly, placenta previa, uterine anomalies and uterine
complicated by diet-controlled gestational fibroids are all associated with breech presentation.
diabetes. She has a history of uterine fibroids. On
examination, she is found to be 4 cm dilated in
breech presentation. An ultrasound confirms the
breech presentation, amniotic fluid index is 5, and
the estimated fetal weight is 3900 g. Which of the
following is the most likely cause of the breech
presentation in this patient?

A. Gestational diabetes
B. Uterine fibroids
C. Oligohydramnios
D. Macrosomia
E. Gravidity
32. A 22-year-old G1P0 woman currently at 38 weeks C. Allowing the parents when to decide to deliver can help the bereavement
gestation complains of decreased fetal movement. process. Keeping the patient adequately anesthetized during the labor and
Ultrasound reveals a 38-week gestation with no delivery as well as letting the parents hold the baby for as long as they desire
cardiac activity. The parents are upset and want to also helps them grieve. Whether to have care on the maternity floor needs to
know the next steps. Which of the following would be the parents' decision as well. Offering an autopsy to determine the cause of
be most helpful to aide the bereavement process? death as well as having someone taking pictures and keeping mementos for
the parents is helpful.
A. Minimize analgesia used during labor
B. Plan for postpartum care on the maternity floor
C. Allow the parents to decide when to deliver
D. Immediately remove the infant from the room
after delivery
E. Avoid requesting an autopsy and stillbirth
evaluation
33. A 22-year-old G1P0 woman presents at 42 weeks D. Prostaglandins applied locally are the most commonly-used cervical
gestation. Her cervix is long and closed. She does ripening agents. RU486 is not used for cervical ripening. Membrane stripping
not report contractions and states there is good (digital separation of chorioamnion from lower uterine segment) and artificial
fetal movement. You discuss the benefits of rupture of membranes cannot be performed in a patient with a closed cervix.
induction at this time versus waiting until she goes The American College of Obstetricians and Gynecologists (ACOG)
into labor spontaneously. She agrees to proceed recommendations for the management of postterm pregnancy includes
with an induction. Which of the following is the patient records fetal kick counts and fetal surveillance using one of the
best next step in the management of this patient? following: NST, CST, biophysical profile and delivery for nonreassuring testing.
If the patient has a favorable cervix, induce at 42 weeks and, if the cervix is
A. Artificial rupture of membranes unfavorable, use cervical ripening agents.
B. Membrane stripping
C. Oxytocin infusion
D. Prostaglandin E1 tablet
E. RU486 (progesterone antagonist)
34. A 22-year-old G1P0 woman presents to the emergency department
at eight weeks gestation experiencing heavy vaginal bleeding. On
physical exam: blood pressure 94/60; pulse 108; respirations 20; and
temperature 98.6F (37.0C). Pelvic examination demonstrates brisk
bleeding through a dilated cervical os. The patient's hemoglobin is 7
g/dL (hematocrit 21%). Which of the following is the most appropriate
next step in the management of this patient?
A. Administration of intravaginal misoprostol
B. Administration of oral misoprostol
C. Dilation and suction curettage
D. Endometrial ablation
E. Expectant care to permit spontaneous abortion
35. A 22-year-old G1P1 woman delivered her first baby five days ago
after a prolonged labor and subsequent Cesarean section for arrest
of cervical dilation at 7 cm. Fever was noted on postoperative day
two and, despite broad spectrum antibiotics, she continues to have
temperature spikes above 101.3 F (38.5 C). She is eating a normal
diet and ambulating normally. On physical examination, her breasts
have no erythema and nipples are intact. Her abdomen is soft,
uterine fundus is firm and nontender, and her incision is healing
without induration or erythema. She has normal lochia and her
urinalysis is normal. Pelvic examination reveals a firm nontender
uterus and no adnexal masses or tenderness. Which of the following
is the most likely cause of her fevers?
A. Mastitis
B. Endometritis
C. Ovarian abscess
D. Cystitis
E. Septic pelvic thrombophlebitis
36. A 22-year-old G1P1 woman delivered her first baby five days ago
after a prolonged labor and subsequent Cesarean section for arrest
of cervical dilation at 7 cm. Fever was noted on postoperative day
two and, despite intravenous broad spectrum antibiotics, she
continues to have temperature spikes above 101.3 F (38.5 C). She is
eating a normal diet and ambulating normally. On physical
examination, her breasts have no erythema and nipples are intact.
Her abdomen is soft, uterine fundus is firm and nontender, and her
incision is healing without induration or erythema. She has normal
lochia and her urinalysis is normal. Pelvic examination reveals a firm
nontender uterus and no adnexal masses or tenderness. Which of the
following treatments is indicated for this patient?
A. Addition of antifungal therapy
B. Addition of oral antibiotic therapy
C. Addition of antiviral therapy
D. Surgical exploration
E. Heparin anticoagulation
C. This patient is actively bleeding and is anemic. She,
therefore, requires immediate surgical treatment consisting
of dilation and suction curettage. Although clinicians
increasingly utilize both expectant management and
various drug regimens to treat spontaneous abortion, a
prerequisite for either is that the patient is hemodynamically
stable and reliable for follow-up care. She is not
hemodynamically stable. Endometrial ablation will not work
in this case, as the products of conception need to be
evacuated to control the bleeding.
C. Septic thrombophlebitis involves thrombosis of the
venous system of the pelvis. Diagnosis is often one of
exclusion of other causes, but sometimes a CT scan will
reveal thrombosed veins. Treatment requires addition of
anticoagulation to antibiotics and resolution of fevers is
rapid. Anticoagulation treatment is short-term. Classic
clinical findings for endometritis include fever and maternal
tachycardia, uterine tenderness and no other localizing
signs of infection. The clinical manifestations of cystitis
include lower abdominal pain, frequency, urgency and
dysuria. The clinical findings in patients with mastitis include
fever, tenderness, induration and erythema of the affected
breast.
E. Septic thrombophlebitis involves thrombosis of the
venous system of the pelvis. Diagnosis is often one of
exclusion of other causes, but sometimes a CT scan will
reveal thrombosed veins. Treatment requires addition of
anticoagulation to antibiotics and resolution of fevers is
generally rapid. Anticoagulation treatment is short-term.
The addition of oral antibiotics has no extra benefit on a
patient who is already on broad spectrum IV antibiotics.
She has no evidence of fungal or viral infections, so
therapy for these is not indicated. There is also no
indication she needs surgery.
37. A 22-year-old G1P1 woman with no
prenatal care delivered a 2100 g
female infant. The infant had a
spontaneous cry upon delivery. The
baby's father is concerned because
his new daughter's skin appears to be
peeling and has a green/yellow hue,
and her fingernails are very long.
Overall both parents are concerned,
as the baby appears to be thin and
fragile. Which of the following
diagnoses best explains these
findings?
B. The incidence of infants with dysmaturity approaches 10% when the gestational age
exceeds 43 weeks. Infants are described as withered, meconium stained, long-nailed, fragile
and have an associated small placenta. These infants are at great risk for stillbirth. The
diagnosis of dysmaturity is more common in women with unknown last menstrual periods
and unsure dating. While low birth weight is a common finding in infants with Trisomy 18,
overlapping fingers, micronathia, and cardiac defects are the most common findings.
Trisomy 21 can be associated with low birth weight, but the syndrome is characterized by a
constellation of facial findings (low set ears, flattened bridge of the nose, and almond
shaped eyes) and nearly 50% are associated with cardiac defects. Acute fetal hypoxia can
be associated with meconium stained amniotic fluid but not the other findings noted in this
patient. The hallmark of Fragile X syndrome (more common in males than females) is
developmental delay not apparent at birth.

A. Acute fetal hypoxia

B. Fetal dysmaturity
C. Trisomy 18
D. Trisomy 21
E. Fragile X syndrome
38. A 22-year-old G1 woman is C. At a magnesium level of 11 mEq/L, respiratory depression is most likely to occur. The
undergoing treatment with therapeutic magnesium level is between 4-7 mEq/L. Seizures are prevented by the use of
magnesium sulfate for preeclampsia magnesium. Loss of deep tendon reflexes occurs at a level of 7-10 mEq/L. Cardiac arrest
with severe features. She was may occur at a level of 15 mEq/L.
delivered 10 hours ago via Cesarean
section for a non-reassuring fetal
heart rate tracing. She has oliguria
and appears lethargic. On exam, no
deep tendon reflexes can be
appreciated. Her magnesium level is
11 mEq/L. Which of the following
conditions is most likely to occur in
this patient?

A. Seizures
B. Paralysis
C. Respiratory depression
D. Pulmonary edema
E. Cardiac arrest
39. A 22-year-old G2P1 woman has a
history of a previous postterm
pregnancy. She delivered a 3500 g
healthy male infant at 42- weeks
gestation via a Cesarean section
secondary to fetal distress. She is
currently 15 weeks pregnant, based on
an irregular last menstrual period.
What is the most appropriate
management at this time?
D. The diagnosis of postterm pregnancy is based on the establishment of an accurate
gestational age. In a patient with irregular menses, it is important to obtain an ultrasound
prior to 20 weeks to accurately date the pregnancy. It is reasonable to allow a patient with
reassuring fetal surveillance to go past 41 weeks gestation if her gestational age is
accurately known. However, because of a prior Cesarean birth, consideration should be
given to delivery before 41 weeks. Approximately 50% of patients with a history of a
postterm pregnancy will experience prolonged pregnancy with the next gestation. There is
currently no indication to begin antenatal testing at 40 weeks in this pregnancy.

A. Plan for a repeat Cesarean section

at 38 completed weeks
B. Schedule for a repeat Cesarean
section if she does not go into
spontaneous labor by 40 weeks
gestation
C. Plan to admit the patient for an
induction of labor (a VBAC) if she
does not go into spontaneous labor
by 41 weeks gestation
D. Obtain a fetal ultrasound to date
the pregnancy
E. Start weekly non-stress tests and
amniotic fluid indexes at 40 weeks
gestation and proceed with either
induction of labor or Cesarean section
for a nonreactive non-stress test or
oligohydramnios or if patient has not
gone into spontaneous labor by 41
weeks gestation
40. A 22-year-old G2P1 woman is at 42 C. Optimal management for the patient with an unfavorable cervix at an uncertain 42 weeks
weeks gestation dated by an gestation is arguable. Given the uncertainty of her dates, it is reasonable to follow this
ultrasound performed five weeks ago. patient with antepartum fetal testing, such as twice weekly non-stress tests with amniotic
Her cervix is long and closed. She fluid index. The risk of fetal death is 1-2/1000 high-risk pregnancies with a reassuring NST,
does not report contractions and contraction stress test or biophysical profile. The addition of amniotic fluid assessment may
states there is good fetal movement. improve the predictive value of a reactive NST and reduce the risk of antepartum fetal
She would like to wait until she goes demise to even lower levels. Ultrasound for gestational age determination in the third
into labor spontaneously. Which of the trimester is not useful since the measurement error is +/- 3 weeks. Allowing spontaneous
following treatment options is optimal onset of labor is okay, but not without some type of antepartum surveillance testing.
at this time?

A. Allow the patient to go into labor

spontaneously
B. Perform an ultrasound to determine
gestational age
C. Perform a non-stress test (NST) and
amniotic fluid index (AFI) twice a
week, with induction of labor for a
nonreactive NST or oligohydramnios.
D. Patient should perform daily fetal
movement counts and proceed with
induction for decreased fetal
movement.
E. Perform daily biophysical profiles
and deliver if 4 or less
41. A 22-year-old G2P1 woman presents for prenatal care at
approximately 10 weeks gestation. Her first pregnancy
was complicated by preterm premature rupture of the
membranes at 28 weeks gestation. Which of the
following interventions could reduce the risk of preterm
premature rupture of the membranes during this
pregnancy?
A. Bedrest
B. Placement of a cerclage
C. Placement of a Tertbutaline pump
D. 17 alpha-hydroxyprogesterone
E. Nifedipine
42. A 22-year-old G4P1 woman at 26 weeks gestation
presents complaining of a postcoital musty odor and
increased milky, gray-white discharge for the last week.
This was an unplanned pregnancy. She had her first
pregnancy at age 15. She reports that she has no new
sex partners, but the father of the baby may not be
monogamous. On examination, there is a profuse
discharge in the vaginal vault, which covers the cervix.
Pertinent labs: wet mount pH >4.5 and whiff test positive.
Microscopic exam reveals clue cells, but no
trichomonads or hyphae. Which of the following is the
most appropriate next step in the management of this
patient?
D. Premature rupture of the membranes occurs in approximately 10-15%
of all pregnancies. Preterm premature rupture of the membranes
between 16 and 26 weeks gestation is identified in 1% of pregnancies.
Preterm premature rupture of the membranes occurs in 1/3 of all preterm
deliveries. The reported recurrence rate for preterm premature rupture
of the membranes is approximately 32% when it occurred in the index
pregnancy. Bedrest and tocolytics have not been shown to reduce the
risk for PPROM, and may have detrimental effects to the mother. A
cerclage may be indicated for patients with a history of an incompetent
cervix. 17 alpha-hydroxyprogesterone has been shown to reduce the risk
of premature labor. 17 alpha-hydroxyprogesterone is administered
weekly (starting between 16-20 weeks) until 36 weeks gestation.
C. The patient has bacterial vaginosis. All symptomatic pregnant women
should be tested and treatment should be not be delayed because
treatment has reduced the incidence of preterm delivery. The optimal
regimen for women during pregnancy is not known, but the oral
metronidazole regimens are probably equally effective. Once treated
antepartum, there is no need to treat during labor unless she is
reinfected.

A. Delay treatment until postpartum

B. Treat her now and again during labor
C. Treat her now
D. Treat her and her partner
E. No treatment necessary
43. A 23-year-old G1P0 woman at 24 weeks gestation B. While all the side effects listed are reported in patients on fluoxetine,
requires treatment for depression. She has no other an SSRI antidepressant medication, the most common side effect is
pregnancy complications. In addition to counseling, she insomnia. Significant insomnia may affect one in five patients taking
begins therapy with fluoxetine (Prozac). Which of the SSRIs. In addition to sleep disturbances, sexual dysfunction, such as
following symptoms is the most common side effect of decreased libido and delayed or absent orgasm, are common.
her therapy?

A. Fatigue
B. Sleep disturbance
C. Headache
D. Irritability
E. Agitation
44. A 23-year-old G1P0 woman at 40 weeks gestation presents to labor
and delivery with contractions. At 10:00 am, her cervical exam is 2
centimeters dilated, 70% effaced and the vertex at 0 station. Clinical
pelvimetry reveals an adequate pelvis and membranes are intact. The
fetus is in a cephalic presentation and EFW is 3500 gms. Contractions
are occurring every 3-4 minutes, based on the external monitor. Her
labor slowly progresses and, at 1:00 pm, the patient has spontaneous
rupture of membranes. Fetal surveillance remains Category I. Her
cervical exam is 5 centimeters dilated, 100% effaced, and 0 station. At
4:00 pm, the patient's cervical exam is unchanged. Contractions are
occurring every 5-6 minutes. Which of the following is the most
appropriate next step in the management of this patient?
A. Perform a biophysical profile
B. Have the patient ambulate
C. Perform a Cesarean delivery
D. Continue fetal surveillance and reexamine the patient in two hours
E. Begin oxytocin augmentation
45. A 23-year-old G1P0 woman presents in labor at term. Her prenatal
course was uncomplicated. She delivers a 3500 gram infant
spontaneously after oxytocin augmentation of labor. Immediately
postpartum, there is excessive bleeding greater than 2000 cc. There
are no lacerations and the uterus is found to be boggy. Her blood
pressure is 90/40; pulse is 120. Conservative and medical management
have failed and you proceed with an exploratory laparotomy. Which of
the following is the most appropriate next step in the management of
this patient?
A. Cervical artery ligation
B. Ovarian artery ligation
C. External iliac artery ligation
D. B-Lynch suture
E. Hysterectomy
46. A 23-year-old G1P0 woman presents with cramping, vaginal bleeding
and right lower quadrant pain. Her last normal menstrual period
occurred seven weeks ago. On physical exam, vital signs are: blood
pressure 110/74; pulse 82; respirations 18; and temperature 99.4F
(37.4C). On abdominal exam, she has very mild right lower quadrant
tenderness. On pelvic exam, she has scant old blood in the vagina and
a normal appearing cervix. Her uterus is normal size and slightly
tender. On bimanual exam, there is no cervical motion tenderness, and
she has slight tenderness in right lower quadrant. Quantitative Beta-
hCG is 2500 mIU/ml; progesterone 6.2 ng/ml; hematocrit 34%. The
transvaginal ultrasound shows an empty uterus with endometrial
thickening, a mass in the right ovary measuring 3 x 2 cm and a small
amount of free fluid in the pelvis. Which of the following is the most
appropriate next step in the management of this patient?
A. Methotrexate
B. Antibiotics
C. Observation
D. Dilation and curettage
E. Culdocentesis
E. The patient has an arrest of dilatation in the active
phase of labor. She is only having contractions every 5-6
minutes, so it is reasonable to start oxytocin to increase
the frequency and strength of this patient's contractions.
If the patient does not have cervical change once she is
having more frequent contractions on oxytocin, it would
be reasonable to place an IUPC (intrauterine pressure
catheter) to assess the strength of the contractions. It is
not yet necessary to perform a Cesarean delivery. Further
observation and having the patient ambulate do not
facilitate delivery. A biophysical profile is not indicated in
this situation.
D. A uterine compression suture such as a B-Lynch has
been shown to be effective in the management of
unresponsive uterine atony. Ligation of a number of
pelvic vessels can lead to reduction in the vascular
pressure in the pelvis thus controlling hemorrhage. This is
especially true with internal iliac artery (hypogastric
artery) ligation. However, ligation of the ovarian arteries
should not be undertaken as a primary approach. Ligation
of the external iliac artery results in devascularization of
the leg and, therefore, should not be performed. If these
more conservative maneuvers fail, hysterectomy may be
necessary but should be a last resort considering the age
and parity of the patient.
A. The next best step in management is methotrexate
administration. Certain conditions must be met prior to
initiating methotrexate therapy for treatment of an
ectopic pregnancy. These include: hemodynamic stability;
non-ruptured ectopic pregnancy; size of ectopic mass <4
cm without a fetal heart rate or <3.5 cm in the presence of
a fetal heart rate; normal liver enzymes and renal
function; normal white cell count; and the ability of the
patient to follow up rapidly (reliable transportation, etc.) if
her condition changes. There is no indication for
antibiotics in this scenario. Offering observation delays
treatment and pain control would not address the
underlying cause of the patient's problem. Culdocentesis
is not indicated and would not change the management
of this patient.
47. A 23-year-old G1P1 woman delivered her first baby two
days ago after an uncomplicated labor and vaginal
delivery. She wants to breastfeed and has been working
with the lactation team. Prior to discharge, her temperature
was 100.4 F (38 C) and other vitals were normal. She
denies urinary frequency or dysuria and her lochia is mild
without odor. On examination, her lungs are clear, cardiac
exam normal, and abdomen and uterine fundus are
nontender. Her breasts are firm and tender throughout,
without erythema, and nipples are intact. Which of the
following is the most likely cause of her fever?
D. Breast engorgement is an exaggerated response to the lymphatic
and venous congestion associated with lactation. Milk "let-down"
generally occurs on postpartum day two or three. If the baby is not
feeding well, the breast can become engorged, which can cause a
low-grade fever. Lactating women are encouraged to feed their baby
frequently, and use a breast pump to prevent painful engorgement
and mastitis. Postpartum fever differential includes endometritis,
cystitis and mastitis. These are easy distinguished, based on clinical
findings. Vaginitis is not accompanied by fever. Septic pelvic
thrombophlebitis is a rare condition and characterized by high fever
not responsive to antibiotics and is a diagnosis of exclusion.

A. Endomyometritis
B. Septic pelvic thrombophlebitis
C. Mastitis
D. Breast engorgement
E. Vaginitis
48. A 23-year-old G1P1 woman delivered vaginally at 42-weeks D. Acute cystitis is a common complication after vaginal delivery and
gestation after a prolonged induction of labor. She had an the risk increases with the use of an indwelling catheter. The most
epidural with an indwelling catheter for 36 hours and three common cause of acute cystitis infection is gram-negative bacteria.
IV sites for her intravenous medications. She now complains The major pathogens are E. coli (75%), P. mirabilis (8%), K. pneumoniae
of lower abdominal pain, frequency and dysuria. Her vital (20%), S. faecalis (<5%), and S. agalactiae.
signs are: temperature 98.6 F (37 C); pulse 70; blood
pressure 100/60; and respirations 12. On examination, her
lungs are clear, cardiac exam is normal, abdomen is soft,
uterine fundus is firm and nontender, and she has mild
suprapubic tenderness. Which of the following organisms is
most likely causing her discomfort?

A. Group A streptococcus
B. Proteus mirabilis
C. Klebsiella pneumoniae
D. Escherichia coli
E. Group B Streptococcus
49. A 23-year-old G1P1 woman diagnosed with postpartum E. This patient offered thoughts of suicidal ideation, thus inpatient
depression at three months after a spontaneous vaginal management is the most appropriate choice. While behavioral
delivery has suicidal ideation and is desperate for help. psychotherapy is necessary to establish long-term strategies for
Which of the following is the most appropriate next step in coping skills, newer regimens for postpartum depression include the
the treatment of this patient? use of SSRI medication. SSRI medications have been shown to hasten
recovery to a fully functioning state. Antipsychotic medication is not
A. Behavioral psychotherapy indicated without an established diagnosis. Electroconvulsive therapy
B. Anti-depressant medication may be indicated for patients who don't respond to standard
C. Anti-psychotic medication depression treatments.
D. Electroconvulsive therapy (ECT)
E. Inpatient psychiatric admission
50. A 23-year-old G1P1 woman is five days post- D. Mixed bacteria originating from the skin, uterus and vagina cause wound infections
operative from a Cesarean section for arrest after a Cesarean section. Prior to establishing a diagnosis of surgical site infection,
of labor at 7 cm. She now complains of evaluation requires opening the wound, checking for fascial dehiscence, drainage
minimal abdominal pain and drainage from and assessment of the fluid. Packing the wound until it has healed from the base of
the right side of the incision. Lochia is the wound facilitates the healing process. Broad spectrum antibiotics are indicated if
normal and she has no urinary complaints. you suspect cellulitis or abscess.
Her vital signs are normal and she is
afebrile. On physical exam, her lung and
cardiac examinations are normal. Her
abdomen and uterine fundus are nontender.
Her Pfannenstiel incision has tenderness
extending 3 cm from the incision and there
is serous, bloody drainage coming from the
right side. What is the next best step in the
management of this patient?

A. Initiate intravenous antibiotics

B. Initiate oral antibiotics
C. Occlusive dressing to the wound
D. Open drainage of wound
E. Tropical antibiotics to the wound
51. A 23-year-old G2P0 woman at 33 weeks
gestation presents to labor and delivery
with acute nausea, vomiting and epigastric
pain. Her blood pressure is 145/90; she has
1+ protein on a urinalysis. Her labs are
shown below:
Hematocrit: 42%
White blood cell count: 11,000/mcL
Bilirubin: 1.4 mg/dL
Platelets: 42,000/mcL
Lipase: 11 u/L
Aspartate aminotransferase (AST): 391 u/L
Creatinine: 0.8 mg/dL
Alanine aminotransferase (ALT): 444 u/L
Uric acid: 7.7 mg/dL Glucose: 100 mg/dL
Fibrinogen: 405 mg/dL
C. HELLP syndrome is a disease process in the spectrum of severe preeclampsia. The
acronym stands for "hemolysis, elevated liver enzymes, low platelets" and can lead to
swelling of the liver capsule and possibly liver rupture. It may or may not be
accompanied by right upper quadrant pain. It is possible to only have
thrombocytopenia and elevated transaminases without clear hemolysis (elevated
bilirubin and anemia), especially if a diagnosis is made early. This patient does not
have seizures and, therefore, does not have eclampsia. The clinical scenario is not
consistent with hepatitis or cholecystitis. Acute fatty liver almost always manifests late
in pregnancy. Symptoms develop over several days to weeks and include malaise,
anorexia, nausea and vomiting, epigastric pain, and progressive jaundice. In many
women, persistent vomiting in late pregnancy is the major symptom. About half of all
women have hypertension, proteinuria, and edema signs suggestive of preeclampsia.
There is usually severe liver dysfunction with hypofibrinogenemia, hypoalbuminemia,
hypocholesterolemia, and prolonged clotting times. As acute fatty liver worsens
there is marked hypoglycemia.

Which of the following is the most likely

diagnosis in this patient?

A. Mild preeclampsia
B. Hepatitis
C. HELLP syndrome
D. Cholecystitis
E. Acute fatty liver
52. A 23-year-old G2P1 woman at 36 weeks gestation presents
with her third episode of heavy vaginal bleeding. She has
normal prenatal labs and a known placenta previa. She
denies uterine contractions or abdominal pain and reports
good fetal movement. Her vital signs are: blood pressure
100/60; pulse 110; and she is afebrile. Her abdomen and
uterus are non-tender. Fundal height measures 35
centimeters and fetal heart tones reveal a baseline of 140
and are reassuring. Pelvic ultrasound confirms a placenta
previa and the fetus is in the cephalic presentation.
Hematocrit is 29%. Which of the following is the most
appropriate next step in the management of this patient?
A. Tocolysis
B. Induction of labor
C. Cesarean delivery
D. Amniocentesis
E. Administer steroids
53. A 24-year-old G1P0 at 32 weeks gestation presents with
vaginal bleeding most likely caused by placental abruption.
She receives a standard dose of 300 micrograms of
RhoGAM. What amount of fetal blood is neutralized by this
dose?
A. 10 cc
B. 20 cc
C. 30 cc
D. 40 cc
E. 50 cc
54. A 24-year-old G1P0 woman at 12 weeks gestation presents
for prenatal care. She is 5 feet 4 inches tall and weighs 220
pounds (BMI: 37.8 kg/m2). She wants to know if there is an
increased risk on her pregnancy because of her size. Which
of the following is the most common complication in this
patient?
A. Hypertension
B. Preterm labor
C. Post-term pregnancy
D. Small for gestational age
E. Shoulder dystocia
55. A 24-year-old G1P0 woman at 22 weeks gestation with
systemic lupus erythematosus (SLE) presents complaining of
malaise, joint aches, and fever. Physical examination reveals
the following: pulse 88; temperature 98.6F (37.0C);
respiratory rate 22; and BP 150/110 (baseline is 100/70).
Laboratory analysis reveals 1 + proteinuria, AST 35, and ALT
28. Which of the following is the most appropriate initial
therapy for the treatment of this patient?
A. Steroids
B. Nonsteroidal anti-inflammatory drugs (NSAIDs)
C. Azathioprine
D. Cyclophosphamide
E. Magnesium sulfate
C. This patient is near term with a third episode of active bleeding
from a placenta previa. The appropriate next step would be to move
towards delivery via Cesarean section. The patient is not
experiencing contractions, so tocolysis is not necessary and would
not be used with heavy vaginal bleeding. Catastrophic bleeding
could occur due to disruption of blood vessels as the cervix dilates
if a vaginal delivery is pursued, and induction of labor would
therefore be contraindicated. An amniocentesis is not indicated in
this situation. Although the patient is not yet at term, delivery is
appropriate due to the third episode of heaving bleeding at near
term. Administering steroids is not appropriate at this gestational
age.
C. Thirty (30) cc of fetal blood is neutralized by the 300 micrograms
dose of RhoGAM. This is equivalent to 15 cc of fetal red blood cells.
At 28-weeks gestation, 300 micrograms of Rh-immune globulin is
routinely administered after testing for sensitization with an indirect
Coombs' test. Administration is given following amniocentesis at any
gestational age.
A. The body mass index (BMI) is equal to a person's weight in kg
divided by their height in meters squared. The National Heart, Lung,
and Blood Institute identify a normal BMI as 18.5 to 24.9 kg/m2;
overweight as a BMI of 25 to 29.9 kg/m2; and obesity as a BMI of 30
kg/m2 or greater. Obesity is further categorized as class I (BMI: 30
to 34.9 kg/m2), class II (BMI: 35 to 39.9 kg/m2), and class III (BMI: >
or = 40 kg/m2). Increased maternal morbidity results from obesity
and includes chronic hypertension, gestational diabetes,
preeclampsia, fetal macrosomia, as well as higher rates of Cesarean
delivery and postpartum complications. This patient's BMI is
approximately 38 so she is a class II and has over a 7-fold increase
risk for preeclampsia and a 3-fold risk for hypertension.
A. Lupus is notoriously variable in its presentation, course, and
outcome. Clinical manifestations include malaise, fever, arthritis, rash,
pleuro-pericarditis, photosensitivity, anemia, and cognitive
dysfunction. A significant number of patients have renal involvement.
There is no cure and complete remissions are rare. Mild disease may
be disabling because of pain and fatigue. Nonsteroidal anti-
inflammatory drugs are used to treat arthralgia and serositis. Severe
disease is best treated with corticosteroids. Hydroxychloroquine is
used to help control skin manifestations and may be associated with
lupus flares if discontinued. Azathiopine and cyclophosphamide are
not indicated in this patient.
56. A 24-year-old G1P0 woman at 32 weeks gestation presents
with leaking watery fluid from the vagina. On evaluation,
preterm premature rupture of membranes is confirmed.
She has occasional Braxton Hicks contractions associated
with fetal heart rate accelerations. She does not have
vaginal bleeding and vaginal fluid phosphatidylglycerol is
absent. Her blood pressure is 110/70; pulse 90;
temperature 98.6F (37.0C). Fundal height is 30 cm and
her fundus is tender. Amniotic fluid index (AFI) is 4. Which
of the following findings is an indication for delivery in this
patient?
A. Tender uterine fundus
B. Size less than dates
C. Fetal heart rate accelerations
D. Amniotic fluid index of less than 5
E. Absence of vaginal fluid phosphatidylglycerol
57. A 24-year old G1P1 woman had an uncomplicated
Cesarean section 20 hours ago under general anesthesia
secondary to an umbilical cord prolapse. You are called to
evaluate her because her temperature is 102.0 F (38.9 C).
The patient does not have any specific complaints. She has
experienced intermittent chills. Her exam is non-focal.
There is no uterine tenderness. A urine analysis shows no
WBCS and is nitrate and leukocyte estrase negative. What
is the next appropriate step in the management of this
patient?
A. Endometrial cultures
B. Chest X-ray
C. Treatment with intravenous broad spectrum antibiotics
D. Pelvic ultrasound
E. Culture of the incision
58. A 24-year-old G1P1 woman just delivered a healthy infant
at term. She has a history of a psychiatric disorder and was
treated for depression while in college. Which of the
following is she at most increased risk for in the
postpartum period?
A. Postpartum blues
B. Postpartum depression
C. Postpartum psychosis
D. Postpartum anxiety
E. She is not at increased risk for a psychiatric disorder
A. Maternal signs of chorioamnionitis or other evidence of intra-
amniotic infection are indications for delivery. This patient has ruptured
membranes and a tender fundus, which indicate chorioamnionitis.
Labor at 32 weeks would be allowed to progress and prolonged non-
reassuring fetal testing would prompt delivery. There are no criteria for
amniotic fluid index or degree of oligohydramnios as an indication for
delivery. Most authors agree that the achievement of fetal lung
maturity (i.e. positive phosphatidylglycerol or 34 weeks gestational
age) is the threshold at which the risk of morbidity and mortality of
maintaining the pregnancy in utero outweighs the benefits of
prolonging the pregnancy.
B. The lungs are the most common source of fever on the first
postpartum day, particularly if the patient had general anesthesia.
Atelectasis may be associated with a postpartum fever. Aspiration
pneumonia should be considered in patients who had general
anesthesia. Ideally antibiotic treatment should be targeted at a specific
source of infection. Other sources of infection to consider in a febrile
postpartum patient include endometritis, mastitis, the urinary tract, the
wound, and the extremities (thrombophlebitis). Endometrial and
incision cultures are not indicated since her uterus is non-tender and
the incision appears normal.
B. A patient's history of a psychiatric illness is a risk factor for the
development of a postpartum depression. Patients with a prior history
of depression, either situational or spontaneous, are at very high risk
for postpartum depression. In fact, one-third of patients with a
postpartum psychiatric problem report a prior history. These patients
need careful follow up after delivery, which should include an early
appointment for a postpartum visit. Questions at this time should be
directed to her moods and thoughts.
59. A 24-year-old G2P1 woman at 18 weeks gestation
with a history of asthma presents to the office
with worsening symptoms, needing to use her
inhaler more frequently. The symptoms began
with the pregnancy and have gradually
increased. She is using her albuterol inhaler as
needed, recently three times a day. She denies
any illness or fever. She has had asthma since she
was a child. On exam, the patient appears
comfortable. Her temperature is 100.2F (37.9C)
and respiratory rate is 18. Auscultation of the
lungs shows good air movement with mild
scattered end expiratory wheezes. There are no
rales or bronchial breath sounds. Which of the
following is the most appropriate next step in the
management of this patient?
A. Oral theophylline
B. Subcutaneous terbutaline
C. Inhaled corticosteroids
D. Oral zafirlukast (leukotriene inhibitor)
E. Antibiotic treatment
60. A 24-year-old G2P1 woman at 30 weeks
gestation is sensitized to the D antigen. She is
Rh-negative and received RhoGAM after her first
delivery one year ago. Which of the following
statements best explains these findings?
A. The patient initiated her prenatal care late
during the present pregnancy
B. The patient was sensitized during the previous
pregnancy by receiving the RhoGAM
C. Current pregnancy is too close to the first
pregnancy
D. The amount of fetal maternal hemorrhage was
more than previously estimated
E. The cause is most likely idiopathic in this case
61. A 24-year-old G2P1 woman at 42 weeks
gestation presents in early labor. At amniotomy,
there is thick meconium and variable
decelerations are noted. An amnioinfusion is
started. Which of the following is most likely to
decrease in this patient?
A. Admission to the neonatal intensive care unit
B. Post maturity syndrome
C. Repetitive variable decelerations
D. Risk for Cesarean section
E. Meconium presence below the vocal cords
C. Asthma generally worsens in 40% of pregnant patients. One of the indications
for moving to the next line of treatment includes the need to use beta agonists
more than twice a week. The appropriate choice for her treatment would be
inhaled corticosteroids or cromolyn sodium. Theophylline would be used in
more refractory patients. Subcutaneous terbutaline and systemic corticosteroids
would be used in acute cases. Zafirlukast, a leukotriene receptor antagonist, is
not effective for acute disease. The safety of zafirlukast in pregnancy is not well
established because there is little experience with their use in pregnancy.
Antibiotic treatment is only used when a pulmonary infection is diagnosed.
D. On rare occasion, an Rh-negative woman will subsequently be sensitized,
despite prophylaxis. The protection afforded by a standard RhoGAM
administration is dose-dependent. One dose will prevent Rh sensitization to an
exposure of as much as 30 cc of Rh-positive red blood cells. With greater
exposure, there is only partial protection and Rh sensitization may occur as a
result of failure to diagnose massive transplacental hemorrhage. Alternatively,
an Rh-negative woman may be sensitized in the latter part of pregnancy or
soon after delivery before the post-delivery prophylaxis dose is given.
Inadvertent maternal transfusion of Rh-positive blood may result in Rh
sensitization to the D or another red blood cell antigen. Patients may become
sensitized if they do not receive RhoGAM following an episode of antenatal
bleeding or after an invasive procedure, such as amniocentesis or chorionic
villus sampling. In addition, RhoGAM only confers protection against the D
antigen. Therefore, despite administration of RhoGAM to Rh-negative patients,
they may still become sensitized to other red blood cell antigens. Pregnancy
spacing does not affect the presence of the antibody.
C. Amnioinfusion is a procedure where normal saline is infused into the
intrauterine cavity. Amnioinfusionremains a reasonable approach in the
treatment of repetitive variable decelerations, regardless of amniotic fluid
meconium status. Meconium staining of the amniotic fluid is three to four times
more common in the postterm pregnancy. This is likely due to two reasons: 1)
greater length of time in utero allows for activation of a more mature vagal
system; and 2) fetal hypoxia. Routine prophylactic amnioinfusion for thick
meconium does not appear to decrease the incidence of meconium aspiration
syndrome or have an impact on neonatal outcomes. Based on current literature,
routine prophylactic amnioinfusion for meconium-stained amniotic fluid is not
recommended.
62. A 24-year-old G2P1 woman has a fetus that is
affected by Rh disease. At 30 weeks gestation,
the delta OD450 (optical density deviation at 450
nm) results plot on the Liley curve in Zone 3,
indicating severe hemolytic disease. Which of the
following is the most appropriate next step in the
management of this patient?
A. Immediate Cesarean delivery
B. Induction of labor
C. Intrauterine intravascular fetal transfusion
D. Umbilical blood sampling
E. Maternal plasmapheresis
63. A 24-year-old G2P1 woman is diagnosed with Rh
hemolytic disease at 24 weeks gestation.
Measurement of which of the following in the
amniotic fluid is best indicative of the severity of
the disease?
A. Hemoglobin
B. Iron
C. Anti-D antibody titer
D. Ferritin
E. Bilirubin
64. A 24-year-old G2P1 woman is undergoing a
Cesarean delivery for placental abruption. She
presented to labor and delivery with severe
abdominal pain and heavy vaginal bleeding. The
fetus was delivered uneventfully. The placenta
delivered with a significant clot attached to the
maternal surface. The patient continues to bleed
from the placental bed. Estimated blood loss is
1500 ml. The operative team decides to give her
fresh frozen plasma (FFP) to replace which of the
following components?
A. Platelets
B. Von Willebrand's factor
C. Red blood cells
D. Fibrinogen
E. Factor X
C. Values in Zone 3 of the Liley curve indicate the presence of severe hemolytic
disease, with hydrops and fetal death likely within 7-10 days, thus demanding
immediate delivery or fetal transfusion. At 30 weeks gestation, the fetus would
benefit from more time in utero. An attempt should be made to correct the
underlying anemia. Intravascular transfusion into the umbilical vein is the
preferred method. Intraperitoneal transfusion is used when intravascular
transfusion is technically impossible. If fetal hydrops is present, the reversal of
the fetal anemia occurs much more slowly via intraperitoneal transfusion.
Percutaneous umbilical blood sampling should not be used as a first-line
method to evaluate fetal status. Maternal plasmapheresis is used in severe
disease when intrauterine transfusions are not possible.
E. In the presence of a severely erythroblastotic fetus, the amniotic fluid is
stained yellow. The yellow pigment is bilirubin, which can be quantified most
accurately by spectrophotometric measurements of the optical density
between 420 and 460nm, the wavelength absorbed by bilirubin. The deviation
from linearity of the optical density reading at 450nm is due to the presence of
heme pigment, an indicator of severe hemolysis. Amniotic fluid ferritin, an acute-
phase reactant, is associated with spontaneous preterm delivery and not with
Rh isoimmunization.
D. Correcting coagulation deficiencies requires replacing all necessary blood
components. Fresh frozen plasma contains fibrinogen, as well as clotting factors
V and VIII. Cryoprecipitate contains fibrinogen, factor VIII and von Willebrand's
factor. Neither of these preparations contains red blood cells or platelets, which
must be given separately.
65. A 24-year-old G3P0 woman at 26 weeks gestation was brought to the hospital
by paramedics. Her husband found her shivering and barely responsive. Two
days prior, the patient noted that she was feeling sick, with a slight cough. She
was having back pain at the time, but thought it was probably normal for
pregnancy. Her pregnancy has been uncomplicated except for the recent
diagnosis of gestational diabetes. On exam, vital signs are: temperature 100.2F
(37.9C); pulse 160; and blood pressure 68/32; respiratory rate 32. Oxygen
saturation is 82% on room air. There is no apparent fundal tenderness, although
the patient exhibits pain with percussion of the right back. Fetal heart tones are
not audible. There is no evidence of vaginal bleeding. Extremities are cool to
touch. White blood cell count 24,000; hemoglobin 9.5; hematocrit 27%. Urine
microscopic analysis shows many white blood cells. What is the most likely
etiology for this patient's disease?
A. Abruptio placentae
B. Pyelonephritis
C. Diabetic ketoacidosis
D. Chorioamnionitis
E. Pneumonia
66. A 24-year-old G4P0 woman presents to your office at seven weeks gestation
after two days of bleeding and cramping. She thinks that she miscarried at
home and brought in the tissue for pathologic evaluation. What is the
karyotype most likely to be found on chromosomal analysis?
A. Turner Syndrome (45, X)
B. Autosomal Trisomy
C. Monoploidy
D. Triploidy
E. Tetraploidy
67. A 24-year-old Rh-negative G1P1 woman just delivered a healthy term infant
who is Rh-positive. You recommend RhoGAM administration but she declines
because she does not desire any blood products. What is her approximate risk
of isoimmunization if she does not receive the RhoGAM?
A. Less than 20%
B. 40%
C. 60%
D. 80%
E. 100%
B. This is a patient in septic shock. The most
common cause of sepsis in pregnancy is acute
pyelonephritis. Given the absence of bleeding,
the clinical picture is not suggestive of placental
abruption. Diabetic ketoacidosis is unusual in
gestational diabetic patients. Chorioamnionitis
and pneumonia may both lead to sepsis, but are
not suggested by the clinical picture.
B. Autosomal trisomy is the most common
abnormal karyotype encountered in spontaneous
abortuses, accounting for approximately 40-50%
of cases. The most common chromosomal
aneuploidy noted in abortuses is Trisomy 16.
Triploidy accounts for approximately 15%, and
tetraploidy for 5% of cases. Monosomy X (45X, 0)
is seen in 15-25% of losses.
A. The risk of isoimmunization is 2% antepartum,
7% after full term delivery, and 7% with
subsequent pregnancy so less than 20% total.
While 75% of all gravidas have evidence of
transplacental hemorrhage during pregnancy or
immediately after delivery, 60% of these patients
have <0.1 cc of fetal blood in the maternal
circulation, which is enough to sensitize a patient.
The incidence and size of transplacental
hemorrhage increases as pregnancy advances.
During the second month of gestation, 5-15% of
women will have evidence of feto-maternal
hemorrhage. By the third trimester, this number
increases to 45% of patients.
68. A 24-year-old Rh-negative G2P1 woman at 18
weeks gestation is positive for anti-D antibodies.
In discussing the risks of Rh sensitization with her,
you tell her that her fetus may be at increased
risk of significant perinatal disease including fetal
anemia. Which of the following non-invasive tests
can detect severe fetal anemia?
A. Umbilical artery systolic-diastolic ratio
B. Biophysical profile
C. Amniotic fluid index
D. Umbilical artery blood flow
E. Middle cerebral artery peak systolic velocity
69. A 24-year-old Rh-negative G2P1 woman is found
at 10 weeks gestation to have anti-D antibodies.
You follow her closely during this pregnancy and
order serial ultrasound examinations. Which of
the following fetal ultrasound findings would be
most explained by the presence of Rh disease?
A. Meconium
B. Fetal bladder obstruction
C. Oligohydramnios
D. Pericardial effusion
E. Placenta previa
70. A 25-year-old G0 woman presents to her doctor
for preconception counseling. She is healthy
without significant medical problems. She takes
no medications. She smokes one pack of
cigarettes per day since age 16 and drinks
occasionally. She weighs 140 pounds and her vital
signs and examination are normal. The patient is
at increased risk of which of the following during
her pregnancy?
E. Noninvasive diagnosis of fetal anemia can be performed with Doppler
ultrasonography. The use of middle cerebral artery peak systolic velocity in the
management of fetuses at risk for anemia because of red cell alloimmunization
has emerged as the best test for the noninvasive diagnosis of fetal anemia. All
the other listed tests are for assessment of fetal well-being and non-specific to
detect fetal anemia. Amniocentesis and cordocentesis have been used for many
years to diagnose fetal anemia due to red cell alloimmunization. These
techniques, however, are invasive and many complications are associated with
their use.
D. Fetal hydrops is easily diagnosed on ultrasound. It develops in the presence
of decreased hepatic protein production. It is defined as a collection of fluid in
two or more body cavities, such as ascites, pericardial and/or pleural fluid and
scalp edema. On occasion, when extramedullary hematopoiesis is extensive,
there will be evidence of hepatosplenomegaly. Placentomegaly (placental
edema) and polyhydramnios are also seen on ultrasound. Meconium, fetal
bladder obstruction, oligohydramnios and placenta previa do not fit the clinical
scenario.
C. Smoking increases the risk of several serious complications of pregnancy,
including placental abruption, placenta previa, fetal growth restriction,
preeclampsia and infection. Women who smoke should be counseled
vigorously to quit smoking prior to conception and to resist restarting after the
baby is born.

A. Fetal chromosomal abnormality

B. Breech presentation
C. Placental abruption
D. Cerebral palsy
E. Neural tubal defect
71. A 25-year-old G0 woman presents to the clinic B. Although investigators have implicated all of the listed categories as possible
for follow-up after having a first trimester causes of spontaneous abortion, genetic abnormalities involving the conceptus
spontaneous abortion. She wants to discuss the account for the majority. In fact, approximately 50 to 60 percent of embryos
cause of this event. Which of the following and early fetuses that are spontaneously aborted contain form of chromosomal
etiologic categories accounts for the majority of abnormalities.
first trimester spontaneous abortions?

A. Immunologic abnormalities
B. Conceptus genetic anomalies
C. Maternal genetic anomalies
D. Structural/uterine anomalies
E. Uterine infections
72. A 25-year-old G1P0 woman at 29 weeks gestation presents
to labor and delivery complaining of contractions every 3
minutes. On exam, her blood pressure is 120/70; heart rate is
100; temperature is 100.7F (38.2C); and fetal heart tones are
in the 160's. The fetal heart rate tracing is showing deep
variable decelerations, but is otherwise is reassuring. Her
pelvic examination reveals gross rupture of membranes and
her cervix is dilated to 6 cm and ultrasound reveals the baby
is in the breech presentation. What of the following explains
the variable decelerations?
A. Chorioamnionitis
B. Labor
C. Premature Rupture of Membranes
D. Breech presentation
E. Gestational age
73. A 25-year-old G1 woman at 41 weeks gestation presents to
labor and delivery with painful contractions every four
minutes. Her cervix is 5 cm dilated, 90% effaced. On cervical
exam, you are able to feel a fetal body part but it is not the
head. Which of the following is the most likely body part you
were palplating?
A. Foot
B. Hand
C. Buttocks
D. Back
E. Shoulder
74. A 25-year-old G1 woman at term presents in active labor.
Her cervix rapidly changes from 7 centimeters to complete
dilation in 1 hour. She has been pushing for two hours. The
fetal station has changed from -1 to +1. Fetal heart tracing is
Category I. The patient is feeling strong contractions every
three minutes. Which of the following is the most
appropriate next step in the management of this patient?
A. Cesarean delivery
B. Forceps delivery
C. Continued monitoring of labor
D. Augmentation with oxytocin
E. Ultrasound for estimated fetal weight
C. Variable decelerations are a result of cord compression. With
cord compression, initially there is a short increase in fetal heart rate
followed by an abrupt drop in heart rate. As the compression is
released, the fetal heart rate returns to baseline, frequently with a
brief, slight increase. Variable decelerations can occur at any point.
This patient has PPROM and a frequent cause of cord compression
can be lack of amniotic fluid. Chorioamnionitis is an infection of the
amniotic fluid and chorion that explains this patient's fever, but is not
a cause of variable decelerations. Breech presentation, and
gestational age do not cause variable decelerations.
C. Breech presentation occurs in approximately 3-4% of women in
labor overall, and occurs more frequently in preterm deliveries.
Frank breech is the most common type, occurring in 48-73% of
cases and the buttocks are the presenting part. Complete breech is
found in approximately 5-12% of cases and incomplete breech
(footling breech) occurs in approximately 12-38% of cases.
C. Continued monitoring of labor is appropriate if clinical evaluation
indicates that the fetus is not macrosomic or there is no obvious
fetopelvic disproportion. If either were the case, then a Cesarean
delivery would be indicated. At this time, there is no fetal or maternal
indication to perform a forceps delivery because the station is +1.
Augmentation would be indicated if the contractions were
inadequate in intensity or frequency. An ultrasound at this stage of
labor is inaccurate and one relies on clinical estimates of weight.
75. A 25-year-old G2P1 woman at 20 weeks gestation
is diagnosed with preterm premature rupture of
the membranes. She denies labor. She takes
prenatal vitamins and iron. She denies substance
abuse, smoking or alcohol use. Her prior
pregnancy was delivered vaginally at 36 weeks
after preterm rupture of membranes. Her blood
pressure is 110/70; pulse 84; temperature 98.6F
(37.0C). Her amniotic fluid index is 2. The patient's
fetus is greatest risk for which of the following?
A. Preterm premature rupture of the membranes that occurs before viability is
associated with significant risk of poor outcome. Neonatal survival when
rupture occurs between 20 and 23 weeks is approximately 25%. Complications
that may be found in the developing fetus include structural abnormalities that
are primarily deformations (abnormalities that occur due to an insult after a
structure has already formed) rather than malformations (abnormal
development of the structure itself). Pulmonary hypoplasia is seen when
rupture of membranes occurs before 25 weeks gestation because the lack of
amniotic fluid interferes with the normal intrauterine breathing process. The
result is failure of normal development and growth of the respiratory tree.

A. Pulmonary hypoplasia
B. Cardiac anamolies
C. Urinary tract anamolies
D. Microcephaly
E. Compression fractures
76. A 25-year-old G2P1 woman at eight weeks C. Environmental factors, such as smoking, alcohol and radiation are causes of
gestation is diagnosed with a spontaneous spontaneous abortion. Although the risk increases with infections, such as
abortion. Her husband is 40 years old. The patient's listeria, mycoplasma, ureaplasma, toxoplasmosis and syphilis, advancing
past medical history is noncontributory. She gets maternal or paternal age, advancing parity and some mullerian anomalies, the
some exercise regularly and smokes two packs of clinical scenario does not support these as possible causes. An isolated
cigarettes a day. Three years ago, she had a full- history of preeclampsia confers no increase in risk of spontaneous abortion.
term delivery that was complicated by mild
preeclampsia. Which of the following factors is
most likely the cause of this spontaneous
abortion?

A. Infection
B. Advanced paternal age
C. Environmental factors
D. Uterine anomaly (i.e. unicornuate uterus)
E. History of preeclampsia
77. A 25-year-old G2P1 woman presents at 26 weeks A. ! High levels of magnesium sulfate may cause respiratory depression (12-15
gestation with preterm labor. She is currently mg/dl) or cardiac depression (>15 mg/dl). Prior to developing respiratory
receiving tocolytic therapy with magnesium sulfate. depression the patient should have diminished or absent deep tendon reflexes
The patient's nurse is concerned the patient may (areflexia). Magnesium sulfate does not cause hypertension.
have magnesium sulfate toxicity. The patient is
alert and has no complaints. Her contractions have
stopped and her vital signs are stable. Which of
the following findings associated with magnesium
sulfate treatment would this patient experience
before she develops respiratory depression?

A. Areflexia
B. Hyperreflexia
C. Tachycardia
D. Hypertension
E. Oligouria
78. A 25-year-old G2P1 woman states her
gestational age by known LMP is 16 weeks, 3
days. She reports no complaints and is not yet
feeling fetal movement. Her fundal height is 22
cm. The MSAFP (maternal serum alpha
fetoprotein) result is elevated. Which of the
following is the most likely cause for the
abnormal MSAFP result?
C. Alpha fetoprotein (AFP) levels in twin gestations are elevated and should be
roughly twice that seen in singleton pregnancies. An additional clue to a possible
diagnosis of twin gestation is the fundal height exceeding gestational age in
weeks. Other causes of elevated maternal serum AFP include neural tube defects,
pilonidal cysts, cystic hygroma, sacrococcygeal teratoma, fetal abdominal wall
defects, and fetal death. Polyhydramnios is not by itself associated with abnormal
MSAFP levels.

A. Fetal trisomy
B. Polyhydramnios
C. Twin gestation
D. Fetal abdominal wall defect
E. Fetal neural tube defects
79. A 26-year-old G1P0 woman with last menstrual
period 13 weeks ago presents to your office for
her first prenatal visit. She reports vaginal
spotting for the last two days. You perform an
ultrasound that shows an intrauterine
pregnancy consistent with 11 weeks gestation
with no cardiac activity. She denies cramping or
abdominal pain. What is the most important
laboratory test to check for this patient?
B. A maternal blood type should be checked on all women with vaginal bleeding
during pregnancy, unless it was documented earlier in the pregnancy. If the
patient's blood type is Rh-negative, RhoGAM would be indicated to prevent Rh
sensitization. Serial quantitative Beta-hCGs can be useful in confirming an
ongoing pregnancy before fetal heart rate activity can be noted, but in this case
there is a non-viable intrauterine pregnancy. The patient is unlikely to have had
significant blood loss making a blood or platelet count unlikely to be necessary at
this time. Although progesterone levels can be useful in determining if a
pregnancy is failing, the diagnosis is already clear in this case.

A. Quantitative Beta-hCG
B. Maternal blood type
C. Hemoglobin and hematocrit
D. Platelet count
E. Progesterone
80. A 26-year-old G2P0 woman presents for A. Neither controlled trials nor surveillance data support the contention that a
counseling following manual vacuum aspiration single, prior first trimester surgical abortion increases the risk of subsequent first
of an eight-week missed abortion. The patient trimester pregnancy loss. Indeed, first trimester surgical abortion confers no
asks whether an uncomplicated first trimester subsequent obstetric disadvantage, particularly when compared with an
pregnancy termination three years ago might appropriate control population. The clinician should reassure this patient that first
have predisposed her to the subsequent trimester spontaneous abortion is a common occurrence and that she has not
spontaneous abortion. What are the patient's caused this missed abortion.
risks associated with the prior surgical abortion
in the first trimester?

A. Does not predispose the patient to

subsequent spontaneous abortion
B. Increases the risk of spontaneous abortion
two-fold
C. Predisposes the patient to primary infertility
D. Increases the likelihood of subsequent
pregnancy loss in both the first and second
trimesters
E. Increases the likelihood of spontaneous
abortion and future delivery complications
81. A 26-year-old G2P1 woman at 33 weeks
gestation presents in preterm labor. She has a
history of a prior preterm birth at 32 weeks
gestation. She has insulin dependent diabetes
and has a history of myasthenia gravis. She has
regular contractions every three minutes and
fetal heart tones are reassuring. Cervix is 3 cm
dilated and 0 station. Her blood pressure is
140/90. Which of the following is the most
appropriate tocolytic agent to use in this
patient?
A. Nifedipine, a calcium channel blocker, is the best option for her as she has
contraindications to the other agents listed. Terbutaline and ritodrine are
contraindicated in diabetic patients and the FDA made a formal announcement
in 2011 warning against using terbutaline to stop preterm labor, stating that
terbutaline is both ineffective and dangerous if used for longer than 48 hours.
Magnesium sulfate is contraindicated in myasthenia gravis. Indomethacin is
contraindicated at 33 weeks due to risk of premature ductus arteriosus closure.

A. Nifedipine
B. Terbutaline
C. Magnesium sulfate
D. Indomethacin
E. Ritodrine
82. A 27-year-old G1P0 woman at 14 weeks gestation
presents with a two-month history of insomnia,
feeling depressed, and unintentional weight loss.
Symptoms began after the unexpected death of
her father. She is not excited about this
pregnancy and reports no suicidal ideation.
Physical examination reveals a woman of stated
age with a flat affect. Which of the following
therapies is contraindicated in this patient?
A. Paroxetine (Paxil)
B. Sertraline (Zoloft)
C. Fluoxetine (Prozac)
D. Citalopram (Celexa)
E. Bupropion (Wellbutrin)
83. A 27-year-old G1P0 woman at 32 weeks
gestation presents complaining of cough, fever,
chest pain, and dyspnea. Vital signs are pulse
108; temperature 100.5 F (38.0 C); respiratory
rate 22 per minute. Physical examination reveals
right lower lobe bronchial breath sounds. Which
of the following tests would be most appropriate
for making a diagnosis for this patient?
A. This patient has classic depression. The most commonly used antidepressants
are the selective serotonin reuptake inhibitors (SSRIs). One SSRI, paroxetine
(Paxil) has been changed to a category D drug because of the increased risk of
fetal cardiac malformations and persistent pulmonary hypertension. Other SSRI
compounds, fluoxetine, sertraline, and citalopram have not been reported to
cause early pregnancy loss or birth defects in animals or in humans. Because
these agents have few side effects compared with other antidepressants, they
are a good choice for pregnant women. Bupropion is not an MAO inhibitor, nor
is it an SSRI and a report by the Bupropion Pregnancy Registry reports no
unusual effects in 90 exposed pregnancies.
D. This woman presents with classic symptoms and findings for pneumonia. The
typical symptoms include cough, dyspnea, sputum production, and pleuritic
chest pain. Mild upper respiratory symptoms and malaise usually precede these
symptoms, and mild leukocytosis is usually present. Chest radiography is
essential for diagnosis, although radiographic appearance does not accurately
predict the etiology of the pneumonia. Pulmonary function tests, blood and
sputum cultures, serological testing, cold agglutinin identification, and tests for
bacterial antigens are not recommended in uncomplicated pneumonia.

A. Blood cultures
B. Sputum culture
C. Lower extremity dopplers
D. Chest x-ray
E. Pulmonary function tests
84. A 27-year-old G1P0 woman at 34 weeks
gestation presents with increased
swelling in her face and hands over the
last two days. Blood pressure is 155/99. A
24-hour urine sample for protein is 440
mg/dL. BMI is 27. Repeat blood pressure
two days later is 150/92. Which of the
following is the most likely diagnosis in
this patient?
A. This patient has met criteria for the diagnosis of mild preeclampsia based on her
persistent elevation of blood pressure and 24-hour urine results. The amount of protein
excreted in the urine varies throughout the day, therefore a sample is collected over a
24-hour time period. Twenty-four hour urine protein values greater that 300 mg are
required for the diagnosis of mild preeclampsia. Values greater than 5000 mg (or 5 g) are
required for the diagnosis of severe preeclampsia (assuming no other defining criteria
are present such as SBP >160 or DBP >110). This patient has not had a seizure which is the
hallmark of eclampsia syndrome.

A. Preeclampsia
B. Preeclampsia with severe features
C. Eclampsia Syndrome
D. Gestational hypertension
E. Chronic hypertension
85. A 27-year-old G1P0 woman presents to
labor and delivery and is found to have
a fetal demise at 34 weeks gestation.
She did not have access to prenatal care
during the pregnancy. Her vital signs are
normal and she is not in labor. Her
uterus is non-tender and she does not
have any vaginal bleeding or ruptured
membranes on exam. Which untreated
condition is the most likely cause?
A. Uncontrolled glucose is associated with adverse fetal outcome. A patient with type 1
diabetes is at risk for many pregnancy complications, including fetal death and fetal
macrosomia, although fetal growth restriction may also occur. Diabetics also have
increased risk for polyhydramnios, congenital malformations (cardiovascular, neural tube
defects, and caudal regression syndrome), preterm birth, and hypertensive
complications. The anemia most often seen in pregnancy is mild and would not be the
most likely cause. It is unlikely that she has an abruption causing the anemia, but this
should be considered. Hypothyroidism is usually associated with menstrual irregularities
and infertility, and is a less likely cause. Rh sensitization is unlikely since this is her first
pregnancy and she did not have any bleeding or procedures during the pregnancy.

A. Diabetes
B. Anemia
C. Hypothyroidism
D. Herpes
E. Rh-isoimmunization
86. A 27-year-old G1P1 woman with no A. Most depressed patients who are suicidal are relieved to be asked about it. Although
significant prior medical history reports all the items listed are components of a complete history, the most important topic is
three months of low energy, lack of assessment of suicide risk.
enjoyment with her daily activities, early
morning awakening, and trouble
concentrating. What is the next best step
in the assessment of this patient?

A. Risk of suicide
B. Willingness to accept medical
treatment
C. Family history of mental illness
D. Good support system
E. Current medication profile
87. A 27-year-old G1 woman at 36 weeks gestation is
undergoing an induction of labor for preeclampsia
with severe features. She complains of a headache,
right upper quadrant pain and seeing spots.
Admission vital signs are: blood pressure 180/120,
respiratory rate 20, pulse 92. In addition to 10 hours of
oxytocin, she is receiving intravenous magnesium
sulfate 2 g /hour. During the past two hours her urine
output has decreased to 15 mL per hour (down from
40 mL/h) and her respiratory rate is now 10. What is
the next best step in the management of this patient?
A. Continue magnesium sulfate
B. Decrease magnesium sulfate to 1 gram/hour
C. Administer calcium gluconate
D. Increase oxytocin drip
E. Cesarean delivery now
88. A 27-year-old G2P0 woman is diagnosed with an early
first trimester spontaneous abortion. She has a history
of type 1 diabetes mellitus, mild chronic hypertension
and one prior termination of pregnancy. Which of the
following is the most likely cause of this spontaneous
abortion?
A. Prior termination of pregnancy
B. Chronic hypertension
C. Diabetes mellitus
D. Intrauterine adhesions
E. Infection
C. This patient has respiratory depression likely secondary to magnesium
toxicity. In addition to discontinuing the magnesium sulfate, she needs a
dose of calcium gluconate to restore her respiratory function. The classic
signs of magnesium toxicity include muscle weakness and loss of deep
tendon reflexes, nausea, and respiratory depression. If magnesium is given
in high doses, cardiac arrest is possible. Altering the oxytocin drip and a
Cesarean delivery are not indicated at this time.
C. Systemic diseases such as diabetes mellitus, chronic renal disease and
lupus are associated with early pregnancy loss. In women with insulin-
dependent diabetes, the rates of spontaneous abortion and major
congenital malformations are both increased. The risk appears related to
the degree of metabolic control in the first trimester. There are many other
causes of spontaneous abortion, including genetic factors, endocrine
abnormalities, reproductive tract abnormalities, immunologic factors and
environmental factors. The patient's history of mild chronic hypertension
and one prior termination of pregnancy do not increase her risk of a first
trimester loss. Additionally, an uncomplicated termination of pregnancy,
intrauterine adhesions and infection are not likely causes in this scenario.
89. A 27-year-old G2P1 woman at 18 weeks
gestation presents to the emergency
department complaining of fever,
nausea, vomiting, and mid-abdominal
pain for the last 24 hours. For the last
12 hours, she has had no appetite. She
has been healthy, but reports that her
three-year-old son has had diarrhea
for two days. Physical examination
reveals a blood pressure of 100/60;
pulse 88; respiratory rate 18; and
temperature 102.0F (38.9C).
Abdominal examination reveals
decreased bowel sounds and
tenderness more pronounced on the
right than the left. Which of the
following is the next best step in the
management of this patient?
A. Complete blood count
B. X-Ray of the abdomen
C. Helical CT scan
D. MRI
E. Graded compression ultrasound
90. A 27-year-old G2P1 woman at 36 weeks
gestation is admitted for preeclampsia
with severe features. Her blood
pressure is 200/105. Diastolic blood
pressures during her pregnancy have
ranged from 50-60 mmHg. She has
received two doses of IV hydralazine to
lower her blood pressure. What
diastolic blood pressure should you
aim for in this patient?
A. 50-55 mmHg
B. 60-65 mmHg
C. 70-75 mmHg
D. 80-85 mmHg
E. 90-95 mmHg
E. Suspected appendicitis is one of the most common indications for surgical abdominal
exploration during pregnancy. The diagnosis is made based on clinical findings and
graded compression ultrasonography that is sensitive and specific especially before 35
weeks gestation. This noninvasive procedure should be considered first in working up
suspected acute appendicitis. Selective imaging of the appendix using helical computed
tomography may be a safe and potentially reliable tool to accurately identify appendiceal
changes in appendicitis, except that radiation exposure using this test is higher than
graded compression ultrasonography. An MRI would not expose the patient to radiation
but is not the best diagnostic study for appendicitis. A plain abdominal radiograph can be
used to identify air fluid levels or free air but offers little diagnostic value for appendicitis.
The diagnosis of appendicitis is more difficult to make in pregnancy because anorexia,
nausea, and vomiting that accompany normal pregnancy are also common symptoms of
appendicitis. In addition, the enlarged uterus shifts the appendix upward and outward
toward the flank, so that pain and tenderness may not be located in the right lower
quadrant. Appendicitis is easily confused with preterm labor, pyelonephritis, renal colic,
placental abruption, or degeneration of a uterine myoma. Peritonitis and appendiceal
rupture are more common during pregnancy.
E. Treatment with an antihypertensive is indicated for blood pressures persistently greater
than 160 systolic and 105 diastolic. First-line agents include hydralazine (a direct
vasodilator) 5 mg IV followed by 5-10 mg doses IV at 20-minute intervals (maximum dose =
40 mg); or labetalol (combined alpha & beta-adrenergic antagonist) 10-20 mg IV followed
by 20 mg, then 40 mg, then 80 mg IV every 10 minutes (maximum dose = 220 mg). The
goal is not a normal blood pressure, but to reduce the diastolic blood pressure into a safe
range of 90-100 mmHg to prevent maternal stroke or abruption, without compromising
uterine perfusion.
91. A 27-year-old G2P1 woman presents to the emergency
department with increasing lower abdominal pain, nausea,
scant bleeding, and fever. She is two days postop from a
suction dilatation and curettage for an incomplete abortion.
Vital signs: blood pressure 120/80, pulse 104, respiratory
rate 20, and temperature 100.4F (38.0C). Physical
examination reveals rebound tenderness and abdominal
guarding, uterus soft and slightly tender. Which of the
following is most likely in this patient?
A. Normal recovery symptoms
B. Retained products of conception
C. Hematometra
D. Perforated uterus
E. Cervical laceration
92. A 28-year-old G0 woman presents to your office for
preconception counseling. She has a history of type 1
diabetes, diagnosed at age six, and uses an insulin pump for
glycemic control. She has a history of proliferative
retinopathy treated with laser. Her last ophthalmologic
examination was three months ago. Her last hemoglobin
A1C (glycosylated hemoglobin level) six months ago was
9.2%. Which of the following complications is of most
concern for her planned pregnancy?
A. Fetal growth restriction
B. Fetal cardiac arrhythmia
C. Twins
D. Oligohydramnios
E. Macrosomia
93. A 28-year-old G1 at approximately 40 weeks gestation
presents to triage with mild contractions. You measure her
fundal height at 34 cm. You are concerned about
intrauterine growth restriction and you want to confirm her
dates. In reviewing her records, she reports first feeling
fetal movements at 18 weeks gestation. The crown-rump
length measurements determined at eight weeks and femur
length at 20 weeks are consistent with 40 weeks gestation.
Today's assessment reveals biometrics consistent with 34
weeks, amniotic fluid index of 1, and placental calcifications.
Which of the following is considered the most reliable
method of determining the gestational age in this patient?
A. Crown-rump length measurement
B. Second trimester ultrasound
C. Quickening date
D. Third trimester composite biometry
E. Placental calcifications
D. This patient has the classic signs and symptoms of a uterine
perforation. Hematometra can develop after an abortion, but the
patient would complain of cyclic midline abdominal cramping pain.
Retained products of conception would cause profuse vaginal
bleeding and if not removed may lead to a septic abortion.
Complications that may occur secondary to suction dilatation and
curettage include anesthesia risk, bowel and bladder injury, cervical
lacerations, and uterine perforations. If the patient had a cervical
laceration she would have more vaginal bleeding than scant.
A. The patient with type 1 diabetes is at risk for many pregnancy
complications. In women with insulin-dependent diabetes, the rates
of spontaneous abortion and major congenital malformations are
both increased. The risk appears related to the degree of metabolic
control in the first trimester. Overt diabetic patients are also at an
increased risk for fetal growth restriction, although fetal macrosomia
may also occur. The former becomes a greater concern as in this
patient, with longer-term diabetes and vascular complications, such
as retinopathy. Diabetics also have increased risk for polyhydramnios,
congenital malformations (cardiovascular, neural tube defects, and
caudal regression syndrome), preterm birth and hypertensive
complications. Her diabetes does place her at an increased for twins.
A. In order to accurately confirm gestational age at term, one of the
following criteria should be met: Fetal heart tones have been
documented for 20 weeks by a non-electronic fetoscope or for 30
weeks by Doppler; it has been 36 weeks since a positive serum or
urine HCG pregnancy test was performed by a reliable laboratory;
an ultrasound measurement of the crown-rump length, obtained at
six to twelve weeks, supports a gestational age of at least 39 weeks;
and an ultrasound obtained at 13-20 weeks confirms the gestational
age of at least 39 weeks, determined by clinical history and physical
examination. The crown-rump length can reliably date a pregnancy
within five to seven days.
94. A 28-year-old G1P1 woman delivered four days ago. She
tearfully reports that she had trouble sleeping, felt anxious
and has been irritable for the last two days. She feels
somewhat better today, but is still concerned. What is the
most likely diagnosis?
A. Hypothyroidism
B. Postpartum blues
C. Depression
D. Normal postpartum state
E. Anxiety
95. A 28-year-old G1P1 woman presents to your office. She
delivered four weeks ago and tearfully reports that she is
not sleeping, feels anxious and has thoughts of jumping out
her 15th floor window. What is the most likely diagnosis?
A. Postpartum anxiety
B. Postpartum blues
C. Postpartum depression
D. Postpartum psychosis
E. Bipolar disorder
96. A 28-year-old G1 woman at 31 weeks gestation presents
with complaints of fluid leaking from the vagina. Preterm
premature rupture of membranes is diagnosed. The patient
has mild uterine tenderness concerning for early
chorioamnionitis. An amniocentesis is performed. Which of
the following amniotic fluid results is indicative of an intra-
amniotic infection?
A. Presence of leukocytes
B. Low Interleukin-6
C. Amniotic glucose less than 20 mg/dl
D. Elevated level of bilirubin
E. Lecithin/sphingomyelin (L/S) ratio <2
97. A 28-year-old G2P1 woman presents at 20 weeks gestation
for a routine prenatal care visit. This pregnancy has been
complicated by scant vaginal bleeding at seven weeks and
an abnormal maternal serum alpha fetoprotein (MSAFP)
with increased risk for Down syndrome, but normal
amniocentesis: 46, XX. Her previous obstetric history is
significant for a Cesarean delivery at 34 weeks due to
placental abruption and fetal distress. Prenatal labs at six
weeks showed blood type A negative, antibody screen
positive: anti-D 1:64. Which of the following is the most
likely cause of the Rh sensitization?
A. ABO incompatibility
B. Placental abruption
C. Amniocentesis
D. Abnormal maternal serum alpha fetoprotein (MSAFP)
E. First trimester bleeding
B. The patient is describing symptoms of postpartum blues that
affects 40-80% women within two to three days postpartum and
resolve within two weeks. Symptoms include insomnia, easy crying,
depression, poor concentration, irritability or labile affect and anxiety.
Symptoms often last a few hours per day and are mild and transient.
While hyperthyroidism and anxiety may cause insomnia, this is not the
most likely explanation in this patient. Postpartum depression
symptoms, such as mood changes, insomnia, phobias and irritability
are more pronounced than with the blues and last longer than two
weeks.
C. The patient is describing symptoms of depression. Symptoms such
as mood changes, insomnia, phobias and irritability are more
pronounced than with the "blues." She has not described any of the
even more advanced psychotic symptoms of visual or auditory
hallucinations.
C. In some cases of preterm rupture of the membranes,
amniocentesis may be performed to detect intra-amniotic infection.
The presence of amniotic leukocytes has the lowest predictive value
for the diagnosis of chorioamnionitis. Interleukin-6 would be
increased in the setting of chorioamnionitis. A low amniotic fluid
glucose is an indication of intra-amniotic infection. L/S ratio is a
marker for fetal lung maturity.
B. This patient was sensitized during her first pregnancy that was
complicated by abruption and required Cesarean delivery.
Transplacental hemorrhage of fetal Rh-positive red blood cells into
the circulation of the Rh-negative mother may occur following a
number of obstetric procedures and complications, such as
amniocentesis, chorionic villus sampling, spontaneous/threatened
abortion, ectopic pregnancy, dilation and evacuation, placental
abruption, antepartum hemorrhage, preeclampsia, Cesarean delivery,
manual removal of the placenta and external version. ABO
incompatibility is immune system reaction that occurs when blood
from two different and incompatible blood types are mixed together.
98. A 28-year-old G3P2 woman presents in C. Placental abruptions, labor augmentation, degree of parity and circumvallate
labor at 39 weeks gestation and delivers placenta have no impact on the risk of retained placenta. The following are associated
a 3500 gram infant spontaneously after with retained placenta: prior Cesarean delivery, uterine leiomyomas, prior uterine
oxytocin augmentation of labor. Thirty curettage and succenturiate lobe of placenta.
minutes later, the placenta has not
delivered. Her past medical history is
significant for leiomyoma uteri. Her
prenatal course was uncomplicated.
What is the most likely risk factor for
retained placenta in this case?

A. Placental abruption
B. Labor augmentation
C. Leiomyomas
D. Multiparity
E. Circumvallate placenta
99. A 28-year-old G3P3 woman experiences
profuse vaginal bleeding of 700 cc in
one hour following an uncomplicated
spontaneous vaginal delivery of a 4150
gram infant. The placenta delivered
spontaneously without difficulty. Prior
obstetric history is notable for a
previous low transverse Cesarean
delivery, secondary to transverse fetal
lie. The patient had no antenatal
complications. Which of the following is
the most likely cause of this patient's
hemorrhage?
C. Uterine atony is the most common cause of postpartum hemorrhage. Risk factors for
uterine atony include precipitous labor, multiparity, general anesthesia, oxytocin use in
labor, prolonged labor, macrosomia, hydramnios, twins and chorioamnionitis. Patients at
risk for genital tract lacerations are those who have a precipitous labor, macrosomia or
who have an instrument-assisted delivery or manipulative delivery (i.e. breech
extraction). Factors that lead to an over-distended uterus are risk factors for uterine
inversion. Grand multiparity, multiple gestation, polyhydramnios and macrosomia are all
risk factors. The most common etiology of uterine inversion, however, is excessive
(iatrogenic) traction on the umbilical cord during the third stage of delivery. Although
the patient is at risk for uterine dehiscence/uterine rupture because of her history of a
prior Cesarean delivery, these are infrequent occurrences so the most likely cause of
postpartum hemorrhage in this patient is uterine atony.

A. Vaginal or cervical lacerations

B. Uterine inversion
C. Uterine atony
D. Uterine dehiscence
E. Uterine rupture
100. A 28-year-old Rh negative G1P0 woman B. RhoGAM (Anti-D-immunoglobulin) is administered to Rh-negative women to prevent
at eight weeks gestation presents to the isoimmunization. Each dose provides 300 micrograms of D-antibody and is given to the
clinic for a first prenatal visit. Which of D-negative non-sensitized mother to prevent sensitization after any pregnancy-related
the following is the current events that could result in fetal-maternal hemorrhage. Up to 2 percent of women with a
recommendation for RhoGAM spontaneous abortion and 5 percent of those undergoing elective termination may
administration to prevent Rh become isoimmunized without D-immunoglobulin. The current recommendations for Rh-
isoimmunization? negative women without evidence of Rh immunization is prophylactically at 28-weeks
gestation (after an indirect Coombs' test), and within 72 hours of delivering an Rh-
A. Routine administration for every Rh- positive baby, following spontaneous or induced abortion, following antepartum
sensitized woman at term hemorrhage and following amniocentesis or chorionic villus sampling. If the father of the
B. Administration for Rh-negative fetus is known to be Rh-negative, RhoGAM is not necessary since the fetus will be Rh-
patients with no Rh antibodies at 28 negative and not at risk for hemolytic disease.
weeks
C. Administration for every Rh-negative
woman who delivers an Rh-negative
infant
D. Routine administration for all Rh-
negative patients during first trimester
E. Routine administration for all Rh-
negative patients during each trimester
101. A 29-year-old G0 woman presents to your office
for a routine visit. She has been trying to conceive
for the last six months unsuccessfully. She
requests fertility medications and hopes to get
pregnant with twins. What counseling do you tell
her regarding the risks of multifetal gestation?
A. The morbidity with twin gestations is similar to
triplet pregnancies
B. The twin infant death rate is five times higher
than that of singletons
C. The rate of cerebral palsy is double in twin
infants
D. The incidence of abnormal fetal growth is
similar to singleton pregnancies
E. The incidence of prematurity is similar to
singleton pregnancies
102. A 29-year-old G1P0 woman at 28 weeks gestation
presents with preterm labor. She reports having
contractions every 2 minutes and describes them
as painful. On exam, her blood pressure is 130/70;
pulse 92; and is afebrile. Her cervix is dilated to 2
cm/50%effaced/-4 station. The fetus has a
Category I tracing with contractions every 2
minutes. She is admitted and started on nifedipine
and betamethasone. Which of the following
medications is also indicated for this patient?
B. The twin infant death rate is five times higher than that of singletons. The
epidemic of multiple gestations resulting from assisted reproductive techniques
is of great significance to individual parturients and to society because of the
major morbidities associated with twinning as well as with triplets and higher
order multiples. The risk for development of cerebral palsy in twin infants is five
to six times higher than that of singletons. One study, with dichorionic twins,
monochorionic twins and singletons, showed that twins had a higher incidence
of IUGR (intrauterine growth restriction) than singletons. Fifty-eight percent of
twins deliver prematurely, with an average gestational age at delivery of 35
weeks. Twelve percent of twins deliver very prematurely.
D. This patient is in preterm labor. Ampicillin is indicated for this patient as her
Group B Strep status is unknown and should be continued until a culture result
is negative or her labor stops. Nifedipine is a tocolytic used to delay the
progression of labor to allow for the benefit of betamethasone to hasten
pulmonary maturation. Both prostaglandin E1 and E2 are uterotonic agents and
would likely increase the rate of this patient's contractions. Terbutaline is a
tocolytic. The FDA has indicated that terbutaline should not be used secondary
to its side effects and lack of efficacy.

A. Terbutaline
B. Prostaglandin E1
C. Prostaglandin E2
D. Ampicillin
E. No additional medications required
103. A 29-year-old G1P0 woman at 28 weeks gestation D. Fetal macrosomia, maternal obesity, diabetes mellitus, postterm pregnancy,
who is the wife of basketball player is diagnosed a prior delivery complicated by a shoulder dystocia, and a prolonged second
with gestational diabetes. Her BMI is 23.8. Her stage of labor are all associated with an increased incidence of shoulder
mother had a delivery complicated by shoulder dystocia. Although a family history can be indicative of large babies which
dystocia and she is concerned about her own risk. might place her at additional risk, her gestational diabetes represents her
Which of the following is her biggest risk factor largest risk factor.
for shoulder dystocia?

A. Family history
B. Tall husband
C. Maternal weight
D. Gestational diabetes
E. Parity
104. A 29-year-old G1P0 woman at 31 weeks
gestation presents with watery discharge from
the vagina commencing several hours ago.
Her prenatal course has been uncomplicated
and she takes prenatal vitamins and iron. She
denies substance abuse, smoking or alcohol
use. On examination, her blood pressure is
110/70; pulse 84; temperature 98.6F (37.0C).
Which of the following is the most appropriate
next step in the management of this patient?
A. Nitrazine testing of mucus swabbed from
cervix
B. Examination of vaginal fluid for ferning
C. Digital examination of cervix
D. Determination of amniotic fluid index (AFI)
E. Non-stress test
105. A 29-year-old G1P0 woman at 41 weeks
gestation presents for a prenatal visit. Her
prenatal course is complicated by tobacco
abuse and intermittent prenatal care. Her last
visit was at 35 weeks. Prenatal labs are
unremarkable except cervical DNA probe
positive for Chlamydia, which was treated, and
a Pap smear with low-grade squamous
intraepithelial lesion. Ultrasound at 21 weeks
was consistent with gestational age based on
her certain regular LMP. Her vitals reveal a
blood pressure of 128/76; pulse 74; and
temperature 98 F (36.7 C). Fundal height is
39 cm with estimated fetal weight of 2700 gm.
Cervix is dilated to 1 cm, 50% effaced, -2
station. What is the next best step in the
management of this patient?
A. Return visit in one week
B. Non-stress test and assessment of amniotic
fluid volume
C. Ultrasound to assess fetal growth
D. Oxytocin challenge test
E. Cesarean section
B. Methods to confirm rupture of membranes include testing the vaginal fluid for
ferning and nitrazine testing. It is important to test the fluid from the vagina and not
to test cervical mucus because of false positive ferning patterns. A digital exam
should be avoided in a patient you suspect might have preterm rupture of
membranes because of the risk of introducing bacteria into the uterine cavity and
increasing risk for chorioamnionitis. Determination of AFI with ultrasound may
reveal oligohydramnios and support the diagnosis of rupture of membranes, but
does not confirm this diagnosis. Similarly, a non-stress test may reveal variable
decelerations, which may be present in the setting of rupture of membranes.
B. Postterm pregnancies should be followed with antepartum fetal surveillance
because perinatal morbidity and mortality increases beginning at 41 weeks of
gestation. Many practitioners use twice-weekly testing with some evaluation of
amniotic fluid volume beginning at 41 weeks of gestation. A non-stress test and
amniotic fluid volume assessment (a modified BPP) should be adequate. The non-
stress test is an assessment of fetal well-being that measures the fetal heart rate
response to fetal movement. The normal or reactive non-stress test occurs when
there are two fetal heart rate accelerations of 15 beats/minute for 15 seconds within
20 minutes. Contraction stress test assesses uteroplacental insufficiency and looks
for persistent late decelerations after contractions (3/10 minutes); however, it is not
necessary to perform, as the non-stress test will assess fetal well-being, as well. An
ultrasound to assess fetal growth is not indicated as the patient's fundal height is
appropriate for her gestational age and she does not have any other indication to
assess fetal growth such as a history of chronic hypertension or diabetes.
Observation alone would not be proper care as the patient is postterm. Delivery is
indicated if there is evidence of fetal compromise or oligohydramnios.
106. A 29-year-old G1P0 woman at 41 weeks
gestation presents in early labor. The
prenatal course was uncomplicated.
Ultrasound at 21 weeks was consistent
with gestational age. Her vitals reveal a
blood pressure of 128/76; pulse 74; and
she is afebrile. Fundal height is 36 cm
with estimated fetal weight of 2700 gm. A
Cervix is dilated to 1 cm, 50% effaced
and the fetal vertex is at -2 station. The
nurse calls you to evaluate the fetal
tracing. Which statement best describes
the tracing seen below? (baseline 140s,
variability 5-20, no accels no decels.
CTX odd pattern)

A. Normal fetal heart rate with good

variability and regular contractions
B. Fetal tachycardia with good variability
and regular contractions
C. Normal fetal heart rate with poor
variability and regular contractions
D. Fetal tachycardia with poor variability
and irregular contractions
E. Normal fetal heart rate with poor
variability and irregular contractions
107. 29-year-old G1P0 woman at 42 weeks
gestation presents in labor. She denies
ruptured membranes. Her prenatal
course was complicated by chronic
hypertension. Her vital signs are: blood
pressure 130/80; pulse 72; afebrile;
fundal height 36 cm; and estimated fetal
C. Late decelerations are a symmetric fall in the fetal heart rate, beginning at or after the
weight of 2100 gm. Cervix is dilated to 4
peak of the uterine contraction and returning to baseline only after the contraction has
cm, 100% effaced, +1 station. The fetal
ended. Late decelerations are associated with uteroplacental insufficiency. Variable
heart rate tracing is shown below. What
decelerations show an acute fall in the FHR with a rapid down slope and a variable
is the most likely diagnosis?
recovery phase. They are characteristically variable in duration, intensity, and timing, and
(fetal heart rate min after peak of CTX)
may not bear a constant relationship to uterine contractions. Early decelerations are
physiologic caused by fetal head compression during uterine contraction, resulting in
vagal stimulation and slowing of the heart rate. This type of deceleration has a uniform
A. Normal fetal heart rate pattern
shape, with a slow onset that coincides with the start of the contraction and a slow return
B. Sinusoidal rhythm
to the baseline that coincides with the end of the contraction. Thus, it has the
C. Late deceleration
characteristic mirror image of the contraction. The true sinusoidal pattern is a regular,
D. Variable decelerations
smooth, undulating form typical of a sine wave that occurs with a frequency of two to
E. Early decelerations
five cycles/minute and an amplitude range of five to 15 beats per minute. It is also
characterized by a stable baseline heart rate of 120 to 160 beats per minute and absent
beat-to-beat variability.
108. A 29-year-old G1P0 woman at 42 weeks gestation
presents in labor. She denies ruptured membranes.
Her prenatal course was complicated by chronic
hypertension. Her vital signs are: blood pressure
130/80; pulse 72; afebrile; fundal height 38 cm;
and estimated fetal weight of 3000 gm. Cervix is
dilated to 4 cm, 100% effaced, -1 station, and
bulging bag of water. The fetal heart rate tracing
reveals five contractions in 10 minutes and
repetitive late decelerations. What is the most
likely cause of her late decelerations?
A. Uteroplacental insufficiency
B. Umbilical cord compression
C. Uterine hyperstimulation
D. Intrauterine growth restriction
E. Fetal head compression
109. A 29-year-old G1P0 woman at 42 weeks gestation
presents to labor and delivery because of
intermittent contractions. She denies ruptured
membranes. Her prenatal course was
uncomplicated. Her vital signs are: blood pressure
140/96; pulse 72; afebrile; fundal height 32 cm;
and estimated fetal weight of 2900 gm. Cervix is
closed, 25% effaced, -2 station. The fetal heart rate
tracing shows occasional late decelerations. Of the
following, what is the next best step in
management?
A. Maternal left lateral position
B. Intrauterine resuscitation with terbutaline
Start an amnioinfusion
Begin magnesium sulfate
Augment labor with oxytocin
110. A 29-year-old G1P0 woman is at 11 weeks
gestation. She has a history of depression which
has been well controlled with fluoxetine (Prozac).
Although the medication is very helpful in
controlling her depression, she is concerned
about potential side effects on her neonate. Which
of the following conditions in the neonate is
associated with maternal use of Fluoxetine during
pregnancy?
A. Necrotizing enterocolitis
B. Intracranial hemorrhage
C. Agitation and poor feeding
D. Temperature instability
E. Persistent pulmonary hypertension
A. Late decelerations when viewed as repetitive and/or with decreased
variability are an ominous sign. The can be associated with uteroplacental
insufficiency as a result of decreased uterine perfusion or placental function,
thus leading to fetal hypoxia and acidemia. Common causes include chronic
hypertension and postdate pregnancies. Variable decelerations are associated
with cord compression. Uterine hyperstimulation may cause prolonged
bradycardia. While fetuses with intrauterine growth restriction may have late
decelerations, the estimated fetal weight of 3000 g is a normal birth weight for
this gestational age. Fetal head compression may be associated with early
decelerations.
A. Initial measures to evaluate and treat fetal hypoperfusion include a change
in maternal position to left lateral position which increases perfusion to the
uterus, maternal supplemental oxygenation, treatment of maternal
hypotension, discontinue oxytocin, consider intrauterine resuscitation with
tocolytics and intravenous fluids, fetal acid-base assessment with fetal scalp
capillary blood gas or pH measurement. An amnioinfusion may be used to
treat patients with variable decelerations. Measures to improve uteroplacental
blood flow should be attempted prior to proceeding with Cesarean delivery.
Magnesium sulfate is not yet indicated in this patient with one slightly elevated
blood pressure. Augmentation of labor may accentuate the late decelerations.
C. Third trimester maternal use of SSRIs including Fluoxetine has been
associated with abnormal muscle movements (extrapyramidal signs or EPS)
and withdrawal symptoms which may include agitation, abnormally increased
or decreased muscle tone, tremor, sleepiness, severe difficulty breathing, and
difficulty in feeding. In some newborns, the symptoms subside within hours or
days and do not require specific treatment; other newborns may require
longer hospital stays. SSRI use during pregnancy is not associated with
newborn seizures, intracranial hemorrhage or temperature instability. The FDA
has concluded that, given the conflicting results from different studies, it is
premature to reach any conclusion about a possible link between SSRI use in
pregnancy and persistent pulmonary hypertension.
111. A 29-year-old G1P0 woman is at 42 weeks gestation
based on her last menstrual period and a first
trimester ultrasound. Of the following, what factor
is most likely to be associated with postterm
pregnancy?
A. Postterm pregnancies are associated with placental sulfatase deficiency,
fetal adrenal hypoplasia, anencephaly, inaccurate or unknown dates and
extrauterine pregnancy. Postterm pregnancies are not associated with fetal
adrenal hyperplasia, alpha-fetoprotein deficiency, renal anomalies or
chromosomal abnormalities.

A. Placental sulfatase deficiency

B. Fetal adrenal hyperplasia
C. Fetal alpha-fetoprotein deficiency
D. Fetal renal anomalies
E. Fetal chromosomal abnormalities
112. A 29-year-old G1P0 woman presents at 31 weeks
gestation with preterm rupture of membranes six
hours ago. She notes that for the last hour she has
had some occasional contractions. Her prenatal
course has been uncomplicated and she takes
prenatal vitamins and iron. She denies substance
abuse, smoking or alcohol use. Her blood pressure
is 110/70; pulse 84; temperature 98.6F (37.0C).
What is the role of tocolysis in this patient?
D. While the role of tocolysis in the setting of preterm rupture of membranes
is controversial, it may be appropriate in limited settings. Tocolysis may be
administered in an attempt to prolong the interval to delivery to gain time for
steroids to obtain maximum benefit for the fetus. The risks of chorioamnionitis
with continuing tocolytics beyond 48 hours outweighs the benefit of awaiting
lung maturity. This may be reasonable in women without evidence of infection
or advanced preterm labor. Admittedly, the likelihood of success in this
setting is relatively poor, but the potential benefit to the fetus probably
outweighs any maternal complication from tocolysis.

A. Prevent delivery
B. Delay delivery until fetal lung maturity is reached
C. Delay delivery for one week
D. Delay delivery in order to administer steroids
E. Contraindicated
113. A 29-year-old G2P1 woman at 39 weeks gestation D. Uterine inversion is an uncommon etiology of postpartum hemorrhage.
presents in early labor after spontaneous rupture Factors that lead to an over-distended uterus are risk factors for uterine
of the fetal membranes. Thirty minutes after arrival, inversion. Grand multiparity, multiple gestation, polyhydramnios and
she delivers a 2650 gram male infant. A globular macrosomia are all risk factors. The most common risk factor, however, is
pale mass appears at the introitus when attempting excessive (iatrogenic) traction on the umbilical cord during the third stage of
to deliver the placenta. Her blood pressure is delivery. Although leiomyomas may spontaneously prolapse, it is unlikely
90/60; pulse 104; and temperature is 98.6F (37.0C). during the peripartum period.
What is the most likely etiology for this event in this
patient?

A. Multiparity
B. Twin gestation
C. Leiomyoma
D. Uterine inversion
E. Rapid labor
114. A 29-year-old G3P0 woman presents for prenatal care at
eight weeks gestation. Her two prior pregnancies ended in
spontaneous losses at 19 and 18 weeks, respectively.
Records corroborate the patient's history of an
uncomplicated gestation until the evening of the losses,
when she experienced a pink-tinged discharge that
prompted her to call her obstetrician. In both cases, the
obstetrician noted that her cervix had dilated completely
with the amnionic sac bulging into the vagina to the level
of the introitus. The patient was afebrile without other
complaints and there was no uterine tenderness on exam.
She spontaneously delivered the fetus and placenta in
both cases. A sonohysterogram confirmed normal uterine
anatomy several weeks later. What is the most appropriate
next step in the management of this patient?
A. Begin weekly fetal fibronectin testing
B. Placement of a cervical cerclage at approximately 14
weeks gestation
C. Immediate placement of a cervical cerclage
D. Administer low dose aspirin and heparin
E. Administration of prophylactic progesterone
115. A 29-year-old G4P2 woman was diagnosed with twin-twin
transfusion syndrome when an ultrasound was performed
at 24 weeks gestational age. Which of the following is a
complication of twin-twin transfusion syndrome?
A. Fetal macrosomia in the donor twin
B. Neurologic sequelae in the surviving twin
C. Tricuspid regurgitation in the donor twin
D. Heart failure in the donor twin only
E. High perinatal mortality for donor twin only
B. This patient has an incompetent cervix and should have a cervical
cerclage at 14 weeks. A positive fetal fibronectin does not indicate
incompetent cervix and is used later in pregnancy as a negative
predictor of preterm delivery. Pregnancy loss in the late second
trimester is not usually related to genetic abnormality of the
conceptus and most clinicians delay placement of a cerclage until
after the first trimester, given the high background prevalence of first
trimester pregnancy wastage. Although some clinicians strongly
support the existence of an antiphospholipid antibody syndrome, the
term most commonly refers to pregnancy loss or demise, rather than
the clinical scenario of silent cervical dilation with delivery described.
The patient would, therefore, not need aspirin or heparin. Although
some clinicians use prophylactic progesterone to prevent recurrent
abortion, as well as preterm labor, no controlled trials support the use
of prophylactic progesterone in the treatment of cervical
incompetence.
B. Untreated severe twin-twin transfusion syndrome has a poor
prognosis, with perinatal mortality rates of 70-100%. Death in utero of
either twin is common. Surviving infants have increased rates of
neurological morbidity, including an increased risk of cerebral palsy.
Excessive volume can lead to cardiomegaly, tricuspid regurgitation,
ventricular hypertrophy and hydrops fetalis for the recipient twin.
Although the recipient twin is plethoric, it is not macrosomic. The
donor twin becomes anemic and hypovolemic, and growth is retarded.
The recipient twin becomes plethoric and hypervolumic. Either twin
can develop hydrops fetalis. The donor twin can become hydropic
because of anemia and high-output heart failure.
116. A 29-year-old G4P2 woman with no
previous prenatal care presents at 24
weeks gestation with signs and
symptoms of preterm labor. Her
cervix is 3 cm dilated and 80%
effaced. Fundal height is 30 cm and
an ultrasound examination reveals a
twin gestation. Estimated fetal
weights on the twins are 850 gm and
430 gm. The maximum vertical
amniotic fluid pocket around the
smaller twin is 1 cm; the maximum
vertical amniotic fluid pocket around
the larger twin is 8 cm. Which of the
following is the most likely
associated with these ultrasound
findings?
C. Twin-twin transfusion syndrome is the result of an intrauterine blood transfusion from one
twin to the other. It most commonly occurs in monochorionic, diamniotic twins. The donor
twin is often smaller and anemic at birth. The recipient twin is usually larger and plethoric at
birth. Clues to the presence of the twin-twin transfusion syndrome include the large weight
discordance (although this is not necessary for diagnosis), polyhydramnios around the larger
(recipient) twin, and oligohydramnios around the smaller (pump) twin. The two different
placental types in twin gestation are monochorionic and dichorionic. Monozygotic
conceptions may have either monochorionic or dichorionic placentation, depending upon
the time of division of the zygote. Dizygotic conceptions always have dichorionic placentas.
Diamniotic dichorionic placentation occurs with division prior to the morula state (within
three days post fertilization). Diamniotic monochorionic placentation occurs with division
between days four and eight post fertilization. Monoamniotic, monochorionic placentation
occurs with division between days eight and 12 post fertilization. Superfecundation is the
fertilization of two different ova at two separate acts of intercourse in the same cycle.
Isoimmunization is associated with polyhydramnios and fetal hydrops and does not cause
twin-twin transfusion.

A. Dichorionic diamniotic twins

B. Monochorionic monoamniotic
twins
C. Monochorionic diamniotic twins
D. Superfecundation
E. Rh-isoimmunization
117. A 30-year-old G2P1 woman at 38 C. This patient has secondary arrest of dilation, as she has not had any further cervical
weeks gestation presents to labor change in the active phase for over four hours. Amniotomy is often recommended in this
and delivery with contractions every situation. After it is performed, if the patient is still not in an adequate contraction pattern,
2-3 minutes. Her membranes are augmentation with oxytocin can be attempted after careful evaluation. Although the patient
intact. Her cervical examination is 5 requires close monitoring, it is too early to proceed with a Cesarean delivery. An internal
centimeters dilated, 100% effaced, scalp electrode is not necessary, since the fetal heart monitoring is reassuring.
and -1 station. The fetal heart rate
tracing is Category I. Two hours later,
she progresses to 7 cm and 0 station
and receives an epidural for pain.
Four hours after that, her exam is
unchanged (7/100/0). Fetal heart rate
tracing remains Category I. Which of
the following is the most appropriate
next step in the management of this
patient?

A. Allow her to ambulate and return

when she is ready to push
B. Perform a contraction stress test
C. Perform an amniotomy
D. Perform a Cesarean delivery
E. Place an internal fetal scalp
electrode
118. A 30-year-old G2P1 woman with last menstrual
period 10 weeks ago presents for her first prenatal
care visit. She is healthy and takes no medications.
Her previous pregnancy was an uncomplicated
vaginal delivery at 39 weeks. On examination, her
vital signs are normal. Her exam is notable for a
uterus measuring 14 weeks gestation. Ultrasound
shows a diamniotic monochorionic twin gestation at
10 weeks. Which of the following obstetrical
complications is more likely in this pregnancy
compared to her previous pregnancy?
A. Low maternal weight gain
B. Congenital anomalies
C. Induction after 40 weeks
D. Macrosomia
E. Rh isoimmunization
119. A 30-year-old G3P2 woman, whose last normal
menstrual period was eight weeks ago, began
spotting three days ago and developed cramping
this morning. She has a history of a chlamydia
infection with a previous pregnancy. She smokes
one pack of cigarettes per day and denies alcohol
or drug use. On physical exam: blood pressure
120/70; pulse 82; respirations 20; and temperature
98.6F (37.0C). Abdominal examination is normal.
Pelvic examination reveals old blood in the vaginal
vault, closed cervix without lesions, slightly
enlarged uterus and no adnexal tenderness.
Pertinent labs: quantitative Beta-hCG is 1000
mIU/ml; urinalysis normal; hematocrit = 32%.
Transvaginal ultrasound shows no intrauterine
pregnancy, no adnexal masses, and no free fluid in
pelvis. Which of the following is the most
appropriate next step in the management of this
patient?
A. Treat with methotrexate
B. Exploratory surgery
C. Repeat Beta-hCG in 48 hours
D. Repeat Beta-hCG in one week
E. Admit the patient to the hospital for observation
120. A 30-year-old G4P3 woman at 24 weeks gestation is
found to have an anterior placenta previa. She has a
history of three prior Cesarean deliveries. What is
the most likely serious complication that can lead to
obstetric hemorrhage in this woman?
A. Placental abruption
B. Uterine dehiscence prior to labor
C. Uterine inversion
D. Placenta accreta
E. Uterine atony
B. The incidence of congenital anomalies is increased in twins, particularly
monozygotic twins, compared to singletons. The majority of twin pairs in
which an anomaly is present will be discordant for the anomaly. Twin
gestations tend to deliver earlier than singleton gestations, with the average
length of twin gestation being 35-37 weeks. The optimal length of twin
gestation is a matter of some controversy. An observational study
comparing perinatal mortality among twin and singleton gestations showed
that perinatal mortality reached a nadir at 37-38 weeks in twins and then
increased. There have been no prospective studies to demonstrate that
induction of labor after 38 weeks in twin gestations improves perinatal
outcome. Twins typically weigh less than singletons of the same gestational
age, but their weights usually remain within the normal range. Macrosomia is,
therefore, uncommon. Rh isoimmunization is not increased in twin gestations.
C. The patient has risk factors for ectopic pregnancy, but needs an accurate
diagnosis before a treatment plan is entertained. Repeating the Beta-hCG is
the next step in this patient's management. Inappropriately rising Beta-hCG
levels (less than 50% increase in 48 hours) or levels that either do not fall
following diagnostic dilation and curettage would be consistent with the
diagnosis of ectopic pregnancy. Alternatively, a fetal pole must be visualized
outside the uterus on ultrasound. The patient would need a Beta-hCG level
over the discriminatory zone (the level where an intrauterine pregnancy can
be seen on ultrasound) with an empty uterus. The level commonly used is
2000 mIU/ml. Treatment with methotrexate may be appropriate, but only
after a definitive diagnosis is made. The patient does not yet have this level
and is stable. She is, therefore, not a candidate for exploratory surgery. If she
had unstable vital signs or an acute abdomen, a diagnostic
laparoscopy/laparotomy would be indicated. Repeating the ultrasound in
one week is not recommended because a delay in diagnosis could result in a
ruptured ectopic pregnancy and increased risk to the patient. The patient is
hemodynamically stable; therefore, she does not need to be admitted to the
hospital.
D. Placental abruption and uterine atony are both common, but, in the
presence of a low-lying anterior placenta in a patient with a history of
multiple Cesarean births, the diagnosis of the placenta accreta must be
entertained. Placenta accreta is an abnormally firm attachment of the
placenta to the uterine wall. The incidence of placenta accreta may be
increasing because of the rise in the number of women with previous
Cesarean deliveries. This is a serious obstetric complication leading to
retained placenta and severe postpartum hemorrhage. Hysterectomy is
frequently required due to intractable hemorrhage at delivery.
121. A 31-year-old G1 woman presents at term in active labor.
After four hours her cervix is still 5 cm dilated and the fetal
station is zero. The fetal heart rate tracing is Category III. The
patient's contractions have increased in intensity and are
occurring every 2 to 3 minutes. Which of the following is the
most appropriate next step in the management of this
patient?
A. Ambulation
B. Ultrasound for estimated fetal weight
C. Continued monitoring of labor
D. Augmentation with oxytocin
E. Cesarean delivery
122. A 31-year-old G3P0 woman at 27 weeks gestation is being
managed expectantly for preeclampsia with severe features
remote from term. Her blood pressure is 155/100 on
methyldopa (Aldomet) 500 mg three times a day. Her recent
24-hour urine had 6.6 grams of protein. An ultrasound
revealed a fetus with adequate growth, having an estimated
fetal weight in the 10th percentile. Her labs are normal,
except for a uric acid of 8.0 mg/dL; hematocrit 42%
(increased from 37%); and platelet count 97,000. Which of
these findings necessitates delivery at this time?
A. Elevated uric acid
B. Thrombocytopenia
C. Proteinuria
D. Poorly controlled blood pressures
E. Hemoconcentration
123. A 32-year-old G0 woman presents for preconception visit.
She has regular periods reports tension, depressed mood
and decreased productivity towards the end of each cycle.
She is otherwise healthy and maintains a high-profile job. Her
past medical history is benign and she denies prior
psychiatric problems. She denies smoking and drinks alcohol
socially. What is the next best step in the management of this
patient?
A. Reassure her that her monthly symptoms are normal
B. Initiate anti-depressant therapy
C. Psychiatry consult
D. Ascertain the timing of her symptoms each month
E. Initiate psychotherapy
E. This patient needs a Cesarean delivery since she is remote from
delivery with a Category III fetal heart rate tracing. Continued
monitoring of labor would be appropriate if the patient was making
adequate progress and there was a Category I fetal heart rate
tracing. Augmentation of labor would be indicated if there was a
reassuring fetal heart rate tracing and the patient was not making
adequate progress of labor. An ultrasound at this stage of labor is
inaccurate and ambulation in the presence of a non-reassuring fetal
heart tracing is contraindicated.
B. Thrombocytopenia <100,000 is a contraindication to expectant
management of severe preeclampsia remote from term (<32 weeks).
Other contraindications include: inability to control blood pressure
with maximum doses of two antihypertensive medications, non-
reassuring fetal surveillance, liver function test elevated more than
two times normal, eclampsia, persistent CNS (central nervous
system) symptoms and oliguria. Delivery should not be based on
the degree of proteinuria. Although elevated, uric acid and
hemoconcentration are markers of preeclampsia, they are not part
of the diagnostic or management criteria.
D. Ascertaining the timing of her symptoms each month is an
important first step in establishing the proper diagnosis. Symptoms
of Premenstrual Dysphoric Disorder occur in the luteal phase and
are absent in the beginning of the follicular phase. It is therefore
important to document the timing of symptoms each month when
considering a diagnosis of Premenstrual Dysphoric Disorder.
Additionally, it is important to ascertain that these symptoms are not
an exacerbation of an underlying psychiatric disorder before
initiating therapy as this potentially can have more consequences
during her pregnancy and postpartum period.
124. A 32-year-old G1 is at 36
weeks gestation. Ultrasound
reveals limited fetal growth
over the past three weeks.
Biometry is consistent with 30-
5/7, EFW 1900 g, less than 10th
percentile. Which of the
following is LEAST likely to be
associated with this
pregnancy?
A. Fetal demise
B. Perinatal demise
C. Polyhydramnios
D. Meconium aspiration
E. Polycythemia
125. A 32-year-old G1 is seeing you
in consultation at 35 weeks
gestation. Ultrasound reveals
limited fetal growth over the
past three weeks. Biometry is
consistent with 30-5/7, EFW
1900 g, less than 10th
percentile. You counsel her
about short and long-term
complications for her baby.
This fetus is at increased risk
for all of the following adult
disorders EXCEPT:
A. Cardiovascular disease
B. Chronic hypertension
C. Chronic obstructive lung
disease
D. Diabetes
E. Osteoporosis
126. A 32-year-old G1P0 woman at
10 weeks gestation presents to
your office after an ultrasound
evaluation has revealed a
diamniotic, dichorionic twin
gestation. She is very
concerned about the risk for
preterm delivery. Which
intervention would you
recommend as a possible
means to reduce the risk of a
preterm, low-birthweight
infant?
C. This fetus had intrauterine growth restriction and, with the exception of polyhydramnios, all of
the morbidities listed above may complicate intrauterine growth restriction. In general, the causes
of polyhydramnios relate to amniotic fluid production (abnormalities of the fetal urinary tract) and
removal (abnormalities of fetal swallowing and intestinal reabsorption of fluid). Some investigators
report an increase in fetal urinary output when there is hyperglycemia and increased renal osmotic
load, thus resulting in polyhydramnios. Abnormal fetal swallowing may be a result of a CNS or
gastrointestinal tract abnormalities, such as anencephaly, esophageal or duodenal atresia,
diaphragmatic hernia or primary muscular disease. Typically, polyhydramnios is not associated with
asymmetric growth restriction (the most common form of IUGR), since an asymmetric growth
pattern reflects poor uterine blood flow and limited substrate availability. In fact, oligohydramnios
is frequently identified in pregnancies complicated by fetal growth restriction.
E. Epidemiologic studies indicate that fetal growth restriction is a significant risk factor for the
subsequent development of cardiovascular disease, chronic hypertension, chronic obstructive lung
disease and diabetes. Researchers suggest that the phenomenon of programming may be
operable and that an adverse fetal environment during a critical period of fetal growth helps to
promote these adult diseases. Osteoporosis risk factors include family history, slender body
composition, prior history of osteoporosis, Asian and Caucasian ethnicity, alcohol consumption,
smoking, sedentary lifestyle, excess thyroid or corticosteroids and use of anticonvulsant
medications.
E. Although prematurity has been recognized as a major cause of morbidity and mortality among
twin gestations, interventions for prevention of prematurity have, in general, been unsuccessful.
Studies show that an adequate weight gain in the first 20 to 24 weeks of pregnancy is especially
important for women carrying multiples and may help to reduce the risk of having preterm and
low-birth weight babies. These pregnancies tend to be shorter than singleton pregnancies, and
studies suggest that a good early weight gain aids in development of the placenta, possibly
improving its ability to pass along nutrients to the babies. Bed rest, long prescribed by
obstetricians for the prevention of preterm birth, has never been shown to be efficacious, and may
be associated with thromboembolic complications. An observational study of prophylactic
cerclage for twin gestations failed to show any benefit. Tocolytic drugs for prevention of preterm
labor in asymptomatic women with twin gestations have not been shown to be effective. Home
uterine activity monitoring is another intervention that has been shown to be ineffective.

A. Bed rest
B. Cervical cerclage
C. Tocolytics starting at 24
weeks
D. Home uterine monitoring
E. Early, good weight gain
127. A 32-year old G1P0 woman at 29
weeks gestation presents with
preterm labor. She is started on
indomethacin. What is a possible
adverse fetal effect associated with
indomethacin treatment?
B. Maternal indomethacin exposure can result in premature constriction of the ductus
arteriosus, especially if used after 32 weeks gestation. Polyhydramnios is not associated with
indomethacin. In fact, indomethacin is associated with oligohydramnios. Fetal hypoxia and
decreased uteroplacental blood flow have been associated with the use of calcium channel
blockers, such as Nifedipine. Indomethacin should not cause chorioamnionitis.

A. Polyhydramnios
B. Premature constriction of the
ductus arteriosus
C. Fetal growth restriction
D. Hypoxia
E. Chorioamnionitis
128. A 32-year-old G1P0 woman comes to B. The rate of vaginal birth after Cesarean (VBAC) has decreased in recent years due to
your office for her first prenatal care studies that showed an increased risk of complications, especially uterine rupture. This is one
visit. She has recently read an article factor that has led to the increased Cesarean section rate. In addition, although the rate of
about the rising Cesarean section breech and other abnormal presentation is stable, there are significantly fewer obstetricians
rate in the United States and asks you who are willing to perform vaginal breech deliveries (due in part to a lack of training in
about the rate in your hospital. What vaginal breech deliveries). Many obstetricians do not perform instrumental vaginal
do you explain as the major cause of deliveries, such as forceps and vacuum extractions, further contributing to the rising rate.
higher Cesarean delivery rates? Gestational diabetes is a well-known pregnancy complication with clear clinical guidelines.

A. The rate of abnormal

presentations has increased
B. Less women are having vaginal
births after Cesarean
C. Obstetricians' reluctance to
perform forceps delivery
D. Increased rate of fetal macrosomia
due to uncontrolled gestational
diabetes
E. Rate of twins has increased
129. 32-year-old G1P1 is status post uncomplicated normal spontaneous
vaginal delivery. She is taking sertraline (Zoloft), a selective
serotonin uptake inhibitor (SSRI) as an antidepressant and wants to
breastfeed. What is the next best step in management of this
patient?
A. Decrease her SSRI dose by 50%, since these drugs are
concentrated in the breast milk
B. Consult psychiatry about changing medications and discard the
expressed milk in the meantime
C. Discontinue the medications so she can breastfeed
D. Increase her SSRI dose, since these drugs are not concentrated in
the breast milk and she is at great risk for postpartum depression
E. Continue the medications, since there is negligible risk for the
newborn
130. A 32-year-old G1P1 woman delivered a 9-pound baby and sustained
a 4th-degree laceration two days ago. The delivery was complicated
by a shoulder dystocia. Her laceration was repaired in layers in the
customary fashion. She now complains of increasing pain in her
perineal area, fever, chills and weakness. Her vital signs are: blood
pressure 90/50; pulse 120; and temperature 102.2 F (39 C). Her
abdomen is soft, nontender and her uterine fundus is firm and
nontender. Her perineum is erythematous, swollen, but the
laceration edges have separated and are grey. The laceration site is
nontender and without feeling but there is tenderness of the
surrounding tissue. In addition to broad spectrum antibiotics, what is
your next step in the management of this patient?
A. Sitz baths
B. Whirlpool therapy
C. Debridement
D. Repair of laceration site
E. Incision and drainage of perineal laceration
131. A 32-year-old G1 presents at 35 weeks gestation with decreased
fetal movement. Her prenatal course has been complicated by size
less than dates. Serial ultrasounds show a decrease of the estimated
fetal weight from 60th to 20th percentile. The non-stress test is
reactive and the amniotic fluid index is 10. What is your next step in
management?
A. Continue with weekly non-stress tests
B. Obtain umbilical artery systolic: diastolic ratio
C. Admission for daily fetal surveillance
D. Induction of labor today
E. Cesarean section today
E. Breastfeeding is beneficial to both mother and infant.
Current recommendations state that SSRI medications can
be safely used during lactation. Several studies show that
SSRIs are secreted in breast milk, however no detectable
levels of the drug were found in the infants' serum. In
addition, no adverse effects were noted in the infants by
either their parents or pediatricians following the infants.
C. Aggressive debridement of the necrotic areas is required
to prevent further spread of the infection. Debridement
should extend until vital tissue with good blood supply is
encountered. Repair of the defect should be delayed until
the infection has completely resolved. Sitz baths and
whirlpool therapy will provide symptomatic relief for her
discomfort, but not adequate treatment. Incision and
drainage of perineal laceration is appropriate for an
uncomplicated abscess.
A. Since the patient reported decreased fetal movement, a
non-stress was performed and was reassuring. The NST is
based on the principle that when the fetus moves, its
heartbeat normally accelerates. The NST assesses fetal
health through monitoring accelerations of the heart rate in
response to the baby's own movements. Amniotic fluid
volume is important because a decreased amount raises the
possibility that the fetus may be under stress. Since the fetus
does not show growth restriction and fetal status was
reassuring, there are no indications for Doppler studies or
delivery. In light of the dramatic decrease in growth, it is
reasonable to follow this patient with weekly non-stress
tests.
132. A 32-year-old G2P1 woman at 36 weeks gestation
presents with preterm premature rupture of the
membranes that occurred 36 hours ago. She denies
labor. She takes prenatal vitamins and iron. She denies
substance abuse, smoking or alcohol use. Her prior
pregnancy delivered vaginally at 34 weeks after
spontaneous rupture of membranes. Her blood pressure
is 110/70; pulse 84; temperature 98.6F (37.0C). The
estimated fetal weight is 2700 grams. She is having one
contraction per hour and fetal heart tracing is Category
I. Which of the following is the most appropriate next
step in the management of this patient?
A. Observation until spontaneous onset of labor
B. Augmentation of labor
C. Magnesium sulfate
D. Nifedipine
E. Corticosteroids
133. A 32-year-old G2P1 woman is at 41 weeks gestation. Her
cervix is long and closed. She does not report
contractions and states there is active fetal movement.
The patient strongly desires to avoid an induction of
labor. She would like to wait until she goes into labor
spontaneously. Which of the following management
options is optimal at this time?
A. Perform a non-stress test (NST) and amniotic fluid
index (AFI) twice a week with induction of labor for a
nonreactive non-stress test or oligohydramnios
B. Patient should perform daily fetal movement counts
and proceed with induction for decreased fetal
movement
C. Perform daily biophysical profiles and deliver if 4 or
less
D. Immediate induction of labor
E. Immediate Cesarean section
134. A 32-year-old G2P1 woman is at 42 weeks gestation. Her
prenatal course was uncomplicated and she had a first
trimester ultrasound confirming dates. Her cervix is 4 cm
dilated and 100% effaced. She does not report
contractions and states there is good fetal movement.
What is the next best step in the management of this
patient?
A. Ultrasound to assess amniotic fluid volume
B. Twice weekly non-stress test (NST) and amniotic fluid
index (AFI)
C. Daily biophysical profiles
D. Admit for induction
E. Ultrasound to assess fetal growth
B. In this patient, the benefits for delivery outweigh the risk of expectant
management, so the patient should undergo augmentation of labor.
Expectant management at 36 weeks poses a large risk to the
development of chorioamnionitis. The role of tocolytics in the setting of
preterm premature rupture of membranes is controversial and is
contraindicated at 36 weeks gestation. Steroid administration after 32
weeks is controversial.
A. Optimal management for the patient with an unfavorable cervix at 42
weeks gestation is controversial. Induction of labor in a patient with a
reactive tracing and an unfavorable cervix will minimize any risk of
antepartum fetal demise; however, the risk of Cesarean section is
significantly increased compared to a patient who goes into
spontaneous labor. It is reasonable to follow a patient who is 41 weeks
with antepartum fetal testing, such as twice weekly NSTs with amniotic
fluid assessment. The risk of fetal death is 1-2/1,000 high-risk
pregnancies with a reassuring non-stress test, contraction stress test or
biophysical profile. The addition of amniotic fluid assessment may
improve the predictive value of a reactive NST and reduce the risk of
antepartum fetal demise to even lower levels.
D. Optimal management for the patient with a favorable cervix at
greater than or equal to 41 weeks gestation is delivery. Her dilation and
effacement make it likely her induction will be successful. Induction of
labor in a patient with an unfavorable cervix increases the risk of
Cesarean section significantly, compared to a patient who goes into
spontaneous labor. It is not advisable to follow a patient who is >42
weeks with antepartum fetal testing, such as twice weekly non-stress
tests with amniotic fluid index, if the gestational age is certain.
Performing an ultrasound to assess fetal growth and/or amniotic fluid
volume should not change the management plan which should be
induction of labor at this gestational age.
135. A 32-year-old G2P2 woman delivered five days ago by
uncomplicated vaginal delivery. Her postpartum course thus far
has been unremarkable and she is breastfeeding without
difficulty. She woke up in the middle of the night with intense
upper abdominal pain and chills. She admits that she has had pain
like this before, but never this severe. Her vital signs reveal blood
pressure 120/70; pulse 110; and temperature 101.8 F (38.8 C). On
physical examination, she has abdominal pain located in the right
upper quadrant with rebound tenderness. Her uterine fundus is
well below the umbilicus and nontender. Her lochia is normal.
Laboratory tests reveal mild anemia, a slightly elevated white
count and slightly elevated liver function tests. What is the most
likely etiology of her pain?
A. Endomyometritis
B. Ruptured ovarian abscess
C. Hepatitis
D. Cholecystitis
E. Appendicitis
136. A 32-year-old G3P0 woman presents to the clinic for
preconception counseling. Her prior three pregnancies resulted
in first trimester losses. Which of the following tests should be
ordered for this patient?
A. Adrenal stimulation test
B. Clomiphene citrate-FSH challenge test
C. Lupus anticoagulant test
D. Pelvic MRI
E. CT scan of the pelvis
137. A 32-year-old G3P2 woman presents at 40 1/7 weeks gestation
because of regular uterine contractions every five minutes for the
last two hours. Her prenatal course was unremarkable. She states
the baby is moving, but she has had a bright red, bloody
discharge for the last 30 minutes. She does not think she has
ruptured her membranes. Her blood pressure is 120/70; pulse 80;
and she is afebrile. Her abdomen is soft and she has regular
contractions of moderate intensity. Fetal heart tones have a
baseline of 130 with a Category I fetal heart rate tracing. Pelvic
ultrasound reveals a fundal placenta and cephalic presentation of
the fetus. Cervical examination reveals a friable cervix that
bleeds easily and is 5 centimeters dilated and completely
effaced. Membranes are confirmed to be intact. Which of the
following is the most likely source of bleeding?
A. Placental abruption
B. Placenta previa
C. Bloody show
D. Cervical cancer
E. Cervicitis
D. Non-pregnancy related conditions must be considered
when evaluating women in the postpartum period. Pregnancy
puts women at risk for cholelithiasis and, therefore,
cholecystitis. Classic symptoms include nausea, vomiting,
dyspepsia and upper abdominal pain after eating fatty foods.
Treatment would be dependent on the severity of symptoms,
but often involves cholecystectomy that is usually performed
laparoscopically. Classic clinical findings for endomyometritis
include fever and maternal tachycardia, uterine tenderness
and no other localizing signs of infection. This patient is
unlikely to have an ovarian cyst. Appendicitis presents with
nausea, vomiting, anorexia and abdominal pain. Although
hepatitis may be associated with elevated liver function tests,
patients don't typically present with acute severe abdominal
pain.
C. It is important to rule out systemic disease in a patient with
recurrent abortion (three successive first trimester losses).
Testing for lupus anticoagulant, diabetes mellitus and thyroid
disease are commonly performed. Maternal and paternal
karyotypes should also be obtained. Infectious causes should
also be considered. Uterine imaging to exclude a septum or
other anomaly is routinely done using hysteroscopy or
hysterography and not CT or MRI scanning. There is no role
for clomiphene citrate-FSH challenge in the evaluation of this
patient.
C. During pregnancy the cervix is extremely vascular, and with
dilation a small amount of bleeding may occur. This bloody
show is not of clinical significance and often occurs with
normal labor. Serious causes of bleeding, such as placental
abruption and placenta previa, need to be ruled out in order
to make the proper delivery plans. Cervical cancer and
cervicitis are very unlikely causes for the bleeding in this
situation.
138. A 32-year-old G5P3 woman presents with left-sided abdominal pain. Her last
normal menstrual period was eight weeks ago. She began having pain early this
morning and it has increased to a severity of 8/10. She denies nausea or vomiting
or vaginal bleeding. Her gynecological history is notable for a right-sided
ectopic pregnancy four years ago. At that time, she had a right salpingectomy
and a left tubal ligation. On physical examination: blood pressure is 90/54; pulse
108; respirations 22; and temperature 98.6F (37.0C). On abdominal examination,
she has rebound and guarding in all quadrants, and on pelvic exam, her uterus is
very tender and there is left adnexal fullness. Urine pregnancy test is positive. A
transvaginal ultrasound shows a thickened endometrium, left pelvic mass with a
gestational sac and fetal pole, and a large amount of free fluid in the pelvis. Her
hematocrit is 26%. What would be the next best step in the management?
A. Admit for observation
B. Repeat Beta-hCG level in 48 hours
C. Treat with methotrexate
D. Perform a laparoscopy
E. Perform a dilation and curettage
139. A 33-year-old G1P0 woman at 38 weeks gestation with pregnancy complicated
by type 1 diabetes was admitted for induction due to oligohydramnios. She
received Cervidil (prostaglandin E2) overnight and her cervix was noted to be 3
cm dilated in the morning so oxytocin was started. After three hours on oxytocin
induction, fetal heart rate was noted to be in the 160s with minimal variability and
late decelerations despite resuscitation with oxygen, fluids and left lateral
position. Thirty minutes after discontinuing the oxytocin, she continued to have
contractions every three to four minutes with late decelerations. Her blood
pressure was noted to be 138/88 and her pulse was 110. Her cervical exam was
noted to be 4 cm dilated. What is the most appropriate next step in the
management of this patient?
A. Perform a biophysical profile
B. Begin amnioinfusion
C. Administer terbutaline
D. Proceed with a Cesarean section
E. Restart the oxytocin
D. This scenario is consistent with the patient
having a ruptured ectopic pregnancy. Signs of
hypovolemia (tachycardia, hypotension) with
peritoneal signs (rebound, guarding and
severe abdominal tenderness) and a positive
pregnancy test lead to the diagnosis of
ruptured ectopic pregnancy. Conservative
management, with observation and repeating
the Beta-hCG level in 48 hours is not indicated
since a diagnosis is clear and delaying surgery
can potentially be dangerous to the patient.
Dilation and curettage would only be
considered after laparoscopy, if needed.
D. This fetus is clearly not tolerating labor.
Unfortunately, there is no good way to assess
fetal status at this point. A biophysical profile is
not of any value in labor. Amnioinfusion may
be used for repetitive variable decelerations
and not for recurrent lates. The presence of
late decelerations in a patient with diabetes
and oligohydramnios is not reassuring and
unlikely to recover. Although terbutaline may
slow down the contractions, it is not
recommended in a patient whose heart rate is
110.
140. A 33-year-old G2P1 presents at 34 weeks The fetus with enhanced general growth or macrosomia is defined by a birth weight
gestation for consultation because at or above the 90th percentile for gestational age. The condition can usually be
ultrasound revealed a 3900 gm fetus with ascribed to one of three etiologies: enhanced growth potential (50-60%); abnormal
biometrics consistent with 39 weeks. Her maternal glucose homeostasis (35-40%); or underestimation of fetal age (5%).
prior pregnancy was complicated by Macrosomic newborns of diabetic mothers experience excessive rates of neonatal
gestational diabetes and a shoulder dystocia. morbidity, including birth trauma such as shoulder dystocia and brachial plexus
Which of the following complications is this injury. These infants have significantly higher rates of severe hypoglycemia and
fetus at greatest risk? neonatal jaundice. Neonatal acidosis occurs with poor glycemic control, thus
increasing the incidence of fetal demise. While poorly controlled pre-existing
A. Birth trauma diabetes is associated with an increased risk of congenital anomalies, gestational
B. Hyperglycemia diabetes is not associated with increased risk of congenital anomalies.
C. Hypobilirubinemia
D. Hypothyroidism
E. Congenital anomalies
141. A 33-year-old G2P1 presents at 36 weeks C. Delivery is indicated in a fetus with IUGR at 36 weeks gestation with
gestation for consultation because oligohydramnios and abnormal umbilical artery Doppler studies. Although there is
ultrasound revealed a fetus with biometry an increased incidence of fetal intolerance of labor, induction of labor is generally
consistent with 30 5/7 weeks gestation. The preferred over elective Cesarean delivery. Delivery at term is indicated in fetuses
EFW is less than the 5th percentile. Umbilical with IUGR with reassuring fetal testing including a normal amniotic fluid volume.
artery Doppler studies are abnormal. There
is reverse end diastolic flow and the amniotic
fluid volume is decreased. The AFI is 1.1 cm.
Which of the following is the most
appropriate next step in the management of
this patient?
A. Close observation with twice weekly NSTs
and amniotic fluid assessments
B. Close observation with twice weekly NSTs,
amniotic fluid assessments and weekly
umbilical artery Doppler studies
C. Induction of labor
D. Induction of labor at term (37 weeks
gestation)
E. Delivery by Cesarean section
142. A 33-year-old G2P1 woman at 29 weeks A. Antibiotic therapy with ampicillin and erythromycin given to patients with preterm
gestation presents with confirmed preterm premature rupture of the membranes has been found to prolong the latency period
premature rupture of membranes. She denies by 5-7 days, as well as reduce the incidence of maternal amnionitis and neonatal
labor. She takes prenatal vitamins and iron. sepsis. Clindamycin and gentamicin are not indicated for the management of
She denies substance abuse, smoking or PPROM. Tocolytics may also prolong the pregnancy for various lengths of time, but
alcohol use. Her prior pregnancy was generally not seven days.
delivered vaginally at 41 weeks after
spontaneous rupture of membranes. Her
blood pressure is 110/70; pulse 84;
temperature 98.6F (37.0C). Which of the
following is the next best step in the
management of this patient?

A. Ampicillin and erythromycin

B. Clindamycin and gentamicin
C. Nifedipine
D. Terbutaline
E. Magnesium sulfate
143. A 33-year-old G2P1 woman at 39 weeks gestation presents with
painful contractions. Her membranes ruptured two hours prior to
presentation. Her pregnancy has been uncomplicated and she
has a history of a Cesarean section for breech presentation. She
highly desires a vaginal birth. On admission, she is having
contractions every four minutes and fetal heart tracing is
Category I. On cervical exam, she is 5 cm dilated, 80% effaced,
and the fetal vertex is at -1 station. Four hours later, she continues
to contract every four minutes with reassuring fetal status and her
cervical exam is unchanged. What is the next best step in the
management of this patient?
A. Place an intrauterine pressure catheter
B. Administer vaginal prostaglandin E1
C. Administer vaginal prostaglandin E2
D. Perform a vacuum assisted vaginal delivery
E. Perform a Cesarean section
144. A 33-year-old G2P1 woman at eight weeks presents to the clinic.
This is an unplanned pregnancy. She had planned a tubal ligation
six years ago when she was diagnosed with pulmonary
hypertension, but was unable to have the procedure. She states
her pulmonary hypertension has been stable, but she gets short
of breath when climbing stairs. She sleeps on one pillow at night.
What is the concern for her during this pregnancy?
A. There are no additional concerns compared to a normal
pregnancy
B. She will need a Cesarean section at delivery
C. Her baby is at increased risk for pulmonary hypoplasia
D. The mother's mortality rate is above 25%
E. Epidural analgesia is contraindicated
145. A 33-year-old G2P1 woman presents at 12 weeks gestation for
routine prenatal visit. She has had an uncomplicated prenatal
course. Doppler fetal heart tones are not heard and the
ultrasound today shows a crown rump length of 8 mm with no
cardiac activity and a retroverted uterus. What is the next step in
the management of this patient?
A. Check a serum progesterone level
B. Obtain serial Beta-HCG levels every two days
C. Repeat the ultrasound in seven days
D. Medical induction with misoprostol
E. Medical induction with methotrexate
146. A 33-year-old G2P1 woman returns at 16 weeks gestation for a
follow-up prenatal visit. Her first pregnancy was uncomplicated
and delivered at term. Fundal height is 22 cm. Maternal serum
alpha-fetoprotein is 3.0 MoMs (multiples of the median). She has
not felt fetal movement. What is the next best step in the
management of this pregnancy?
A. Repeat the maternal serum AFP
B. Fetal sonogram
C. Biophysical profile
D. Fetal Doppler studies
E. Amniocentesis
A. While the patient is contracting every four minutes, it is not
clear if her contractions are adequate. An intrauterine pressure
catheter (IUPC) will help determine if her contractions are
adequate and if oxytocin augmentation is appropriate.
Prostaglandins are used for cervical ripening and are
contraindicated in patients with history of previous Cesarean
section. While a vacuum assisted delivery is not
contraindicated in a patient with prior history of C-section, it
should not be performed in a patient who is not completely
dilated. A C-section is not indicated yet because it is unclear if
the patient is having adequate strength contractions.
D. Among women with cardiac disease, patients with
pulmonary hypertension are among the highest risk for
mortality during pregnancy, a 25-50% risk for death.
Management of labor and delivery is particularly problematic.
These women are at greatest risk when there is diminished
venous return and right ventricular filling which is associated
with most maternal deaths. Similar mortality rates are seen in
aortic coarctation with valve involvement and Marfan
syndrome with aortic involvement. The baby is not at risk for
pulmonary hypoplasia unless there is very preterm rupture of
the fetal membranes.
D. This patient has a missed abortion and should be offered
uterine evacuation. Ultrasound criteria for a missed abortion
are a CRL of > 7 mm with no cardiac activity. Medical induction
using misoprostol has been shown to be efficacious and
associated with less complications when compared to surgical
evacuation. Checking a serum progesterone and following
serial Beta-hCG may be indicated in confirming a viable
pregnancy. Methotrexate is used in the treatment of selected
ectopic pregnancies and can be used to induce medical
terminations of pregnancies if the LMP was < six weeks ago.
B. In pregnancies with size greater than dates and an elevated
maternal serum AFP, you should consider multiple gestation as
the etiology. Repeating the maternal serum AFP would only
delay further workup. A biophysical profile or fetal Doppler
studies are not indicated or performed at this gestational age.
Amniocentesis is invasive and would not be utilized prior to
performing a fetal survey by ultrasound.
147. A 33-year-old G3P1 woman presents with left lower
quadrant pain of two days duration and seven weeks
of amenorrhea. She describes her pain as mild and
intermittent. Past medical history is significant for
smoking during her teens, ectopic pregnancy with
salpingostomy four years ago, multiple Chlamydia
infections in her teens, and an uncomplicated
Cesarean delivery for breech presentation. Which of
the following risk factors is most likely associated
with recurrent ectopic pregnancy in this patient?
A. Age
B. History of chlamydia infections
C. History of ectopic pregnancy
D. Prior Cesarean delivery
E. Interval between pregnancies
148. A 34-year-old chronic hypertensive G1 comes to see
you for a consultation at 34 weeks for size less than
dates. Her prenatal course has been uncomplicated
and the genetic amniocentesis obtained at 15 weeks
revealed a normal male. Biometrics today reveal a
biparietal diameter consistent with 33 weeks,
abdominal circumference of 28 weeks, EFW 1600 g,
less than 10th percentile, and an amniotic fluid index
of 6. What is the most likely cause of fetal growth
restriction in this patient?
A. Chromosomal abnormality
B. Fetal infection with Rubella
C. Fetal infection with cytomegalovirus (CMV)
D. Uteroplacental insufficiency
E. Maternal infection with Varicella
149. A 34-year-old G1P0 woman is diagnosed with a fetal
demise at 37 weeks. She and her husband seem
stunned. They cannot believe the news. What is the
next psychological response you would expect from
this couple after the initial denial?
A. Depression
B. Anger
C. Assessment
D. Bargaining
E. Acceptance
C. There is a tenfold increase risk for ectopic pregnancy in women with a
prior history of ectopic pregnancy. Age between 35 and 44 years old is
associated with a threefold increase in ectopic pregnancy. Prior abdominal
surgery and history of sexually transmitted infections as well as sterilization
failures, endometriosis and congenital uterine malformations are all
associated with an increased risk of ectopic pregnancy. The interval
between pregnancies and past smoking history is not associated with an
increased risk of ectopic pregnancy.
D. Uteroplacental insufficiency can lead to asymmetric growth restriction.
Asymmetric growth restricted infants typically have a normal length, but
their weight is below normal. On ultrasound, there is a head-sparing effect,
meaning that the head/brain is spared of the reduced blood flow that is a
result of uteroplacental insufficiency. Thus, the fetal abdomen measures
below normal and the head remains very close to normal. There is an
asymmetrical growth pattern that is usually detected during the third
trimester and reflects uteroplacental insufficiency.
Symmetric fetal growth restriction indicates that all fetal measurements are
below normal. As a general rule, such a finding indicates an intrinsic growth
failure or an "early event" secondary to one or more organ system
anomalies, fetal aneuploidy or chronic intrauterine infection. Infectious
diseases are known to cause IUGR, but the number of organisms is poorly
defined. There is sufficient evidence to show a causal relationship between
rubella and CMV infections and fetal growth restriction. Other viruses to
consider are syphilis and varicella. The protozoan toxoplasmosis results in
IUGR as well. There are no bacteria known to cause IUGR. Symmetrical
growth restriction is usually detected in the mid-trimester of pregnancy.
B. Couples who are presented with the news of a fetal birth defect or loss
progress through a series of coping responses. The response to "bad news"
varies with the severity, treatability and the coping level of the couple. As an
individual starts to understand the situation, frustration or anger may be
self-directed or directed to the spouse, the affected child or the caregiver
without a rational basis. This is important to recognize to help the couple
through these stages: Denial, Anger, Bargaining, Depression, Acceptance.
150. A 34-year-old G1P0 woman is in a motor vehicle
accident. While in the emergency department, the
doctors order multiple x-rays to evaluate her injuries. At
what gestational age would the fetus be most
susceptible to developing intellectual disability with
sufficient doses of radiation?
B. The risk of developing microcephaly and severe intellectual disability
is greatest between eight and 15 weeks gestation. In 1990, the
Committee on Biological Effects reported that no risk of mental
retardation (now referred to as intellectual disability) has been
documented with doses even exceeding 50 rad at less than eight weeks
or greater than 25 weeks gestation.

A. 0-7 weeks
B. 8-15 weeks
C. 16-25 weeks
D. 26-30 weeks
E. 31-35 weeks
151. A 34-year-old G1P0 woman presents with vaginal E. Patients experiencing early pregnancy loss can safely consider
spotting. On physical exam: blood pressure 120/70; pulse several different treatments, including expectant management, medical
82; respirations 20; and temperature 98.6F (37.0C). An treatment to assist with expulsion of the pregnancy or surgical
ultrasound confirms a non-viable intrauterine pregnancy. evacuation. Provided the patient is hemodynamically stable and reliable
She is otherwise healthy. Her partner accompanies her for follow-up, expectant management is appropriate therapy. At the
and is supportive. The patient wishes to avoid any gestational age described, expectant management portends no
unnecessary medical interventions and asks whether she increase in risk of either hemorrhage or infection compared with
can safely let nature take its course. What is the best surgical or medical evacuation. Regardless of method chosen, the
next step in the management of this patient? patient's blood type should be checked and rhogam administered as
indicated.
A. Immediate dilation and suction curettage
B. Dilation and suction curettage in one week
C. Immediate treatment with misoprostol
D. Treatment with misoprostol in one week
E. Expectant management
152. A 34-year-old G1 woman at eight weeks gestation D. Screening should be performed between 24 and 28 weeks in those
presents for prenatal care. She is healthy and takes no women not known to have glucose intolerance earlier in pregnancy. This
medications. Family history reveals type 2 diabetes in evaluation can be done in two steps: a 50-g oral glucose challenge test
her parents and brothers. She is 5 feet 2 inches tall and is followed by a diagnostic 100-g oral glucose tolerance test (OGTT) if
weighs 220 pounds (BMI 40.2 kg/m2). Which of the initial results exceed a predetermined plasma glucose concentration.
following is the best recommendation to screen her for Patients at low risk are not routinely screened. For those patients of
gestational diabetes? average risk screening is performed at 24-28 weeks while those at high
risk (severe obesity and strong family history) screening should be done
A. Screen at 24-28 weeks with a 50-g oral glucose as soon as feasible.
challenge test
B. Screen at 16-20 weeks with a 50-g oral glucose
challenge test
C. Screen at 12 weeks with a 50-g oral glucose challenge
test
D. Screen now with a 50-g oral glucose challenge test
E. Begin an oral hypoglycemic agent now
153. A 34-year-old G2P1 woman at 18 weeks gestation presents
with a newly discovered lump in her left breast. Fine
needle aspiration reveals adenocarcinoma. Which of the
following is the least likely recommended therapy for
breast cancer during pregnancy?
A. Wide local excision biopsy
B. Modified radical mastectomy
C. Total mastectomy and node dissection
D. Chemotherapy
E. Radiotherapy
154. A 34-year-old G2P1 woman at 40 weeks gestation with a
history of one prior vaginal delivery strongly desires an
induction of labor, as she is unable to sleep secondary to
severe back pain. Her cervical exam is closed, 20%
effaced and -2 station. The cervix is firm and posterior.
Which of the following is the most appropriate next step in
the management of this patient?
A. Wait until 42 weeks for induction
B. Administer cytotec
C. Insert a foley bulb in the cervix
D. Perform artificial rupture of membranes
E. Perform a Cesarean delivery
155. A 34-year-old G4P3 woman at 19 weeks gestation
presents to the emergency department with chest pain,
palpitations and sweating, which began 2-3 hours ago. On
further questioning, she states that she has been very
anxious lately and is not sleeping well, which she
attributes to the pregnancy. She reports that she has lost
40 pounds in the last year without trying. She denies
significant medical problems. On exam, the patient
appears diaphoretic and anxious, her eyes are wide open,
prominent, with easily visible sclera surrounding the pupil.
Vital signs are: temperature 100.2F (37.9C); pulse 132;
and blood pressure 162/84. Her height is 5 feet 10 inches
and weight is 128 pounds. Her thyroid is palpably
enlarged, with an audible bruit. Electrocardiogram shows
sinus tachycardia. Remaining labs are pending. Which of
the following therapies is contraindicated at this time?
A. Radioactive iodine (I-131)
B. Propylthiouracil (PTU)
C. Propranolol
D. Inorganic iodide
E. Intravenous fluid replacement
E. There is no doubt that breast cancer is more aggressive in younger
women. Whether it is more aggressive during pregnancy in young
women is debatable. Slight delays (1 to 2 months) in clinical
assessment, diagnostic procedures, and treatment of pregnant women
with breast tumors are common. Approximately 30 percent of
pregnant women with breast cancer have stage I disease, 30 percent
have stage II, and 40 percent stages III or IV. Many clinical reports
maintain that when breast cancer is diagnosed during pregnancy, the
regional lymph nodes are more likely to contain microscopic
metastases. Surgical treatment may be definitive for breast carcinoma
during pregnancy and in the absence of metastatic disease a wide
excisional biopsy, modified radical mastectomy, or total mastectomy
with axillary node staging can be performed. Non-pregnant women
receive adjunctive radiotherapy with breast-conserving surgery.
However, this is not recommended during pregnancy due to sizeable
abdominal scatter placing the fetus at significant risk for excessive
radiation.
B. The patient is multiparous at term and waiting until she reaches 42
weeks may increase the risk of perinatal mortality. Since she is
uncomfortable with back pain, it is reasonable to induce labor. Her
cervix is unfavorable; therefore, cytotec administration is appropriate
prior to pitocin induction. A foley bulb or artificial rupture of
membranes cannot be achieved in a patient with a closed cervix. At
this time, there are no indications to perform a Cesarean delivery in
this patient.
A. This patient is in thyroid storm, an acute, life-threatening,
hypermetabolic state. Radioactive iodine (I-131) concentrates in the
fetal thyroid and may cause congenital hypothyroidism, so it should
not be intentionally used in pregnancy. Acute treatment of thyroid
storm may include thioamides (i.e. PTU), propranolol, sodium iodide
and dexamethasone. Oxygen, digitalis, antipyretics and fluid
replacement may also be indicated. Maternal mortality with thyroid
storm exceeds 25%.
156. A 34-year-old G4P3 woman at 36
weeks with a twin gestation presents in
labor. She has three prior normal
spontaneous vaginal deliveries at term,
with the largest infant weighing 3400
grams. Twin A is breech with an
estimated fetal weight of 2800 gm and
twin B is vertex, with an estimated fetal
weight of 3200 gm. Which of the
following is an appropriate delivery
option for this patient?
D. The optimal mode of delivery for twins in which the first twin is in the breech
presentation is by Cesarean section. Similar to singletons, if the first twin is breech
problems can occur including head entrapment and umbilical cord prolapse. When the
presenting twin is vertex and twin B is not vertex, controversy exists as to the optimal
mode of delivery. A small randomized study comparing Cesarean delivery with vaginal
delivery for vertex-non-vertex twins failed to show an advantage for Cesarean delivery,
but did not have statistical power to address rare neonatal morbidities. Some authors
have advocated external cephalic version for management of the second twin; however,
observational studies have not shown any advantage of this approach compared to total
breech extraction.

A. Total breech extraction of twin A,

vaginal delivery of twin B
B. External cephalic version for twin A,
vaginal delivery twin of B
C. Operative vaginal delivery for twin A
and vaginal delivery for twin B
D. Cesarean delivery
E. Vaginal delivery for twin A and
Cesarean delivery for twin B
157. A 35-year-old G1P0 woman at 30- C. Terbutaline is a beta-adrenergic agent. Side effects include tachycardia, hypotension,
weeks gestation is transferred from an anxiety and chest tightening or pain. Tachypnea and headaches are not usual side effects.
outside hospital in preterm labor. Her The FDA made a formal announcement in 2011 warning against using terbutaline to stop
cervix is 3 cm dilated, 50% effaced and preterm labor stating that terbutaline is both ineffective and dangerous if used for longer
the vertex is at 0 station. She is having than 48 hours. The drug may still be used on a short-term basis in patients with active
contractions every five minutes and has contractions, such as those being transferred to another hospital for tertiary care.
no signs consistent with an intra- Alternative tocolytic agents should be used for longer term treatment of preterm labor.
amniotic infection (chorioamnionitis). Non-steroidal anti-inflammatory agents, such as indomethacin can be used as a tocolytic
She was initially treated with terbutaline agent, but would have the side effect of premature closure of the ductus arteriosus if
prior to her transfer. Which of the used beyond 32 weeks gestation. Magnesium sulfate can also be used as a tocolytic and
following side effects would you has the potential side effect of respiratory depression.
expect?

A. Premature constriction of the ductus

arteriosus
B. Respiratory depression
C. Tachycardia
D. Tachypnea
E. Headache
158. A 35-year-old G1P0 woman B. Ultrasound markers suggestive of dizygotic (non-identical) twins include a dividing membrane
with a known twin gestation thickness greater than 2 mm, twin peak (lambda) sign, different fetal genders and two separate
undergoes an ultrasound placentas (anterior and posterior). The two different placental types in twin gestation are
evaluation at 18 weeks. She monochorionic and dichorionic. Dizygotic conceptions always have dichorionic placentas.
would like to know if her twins Monozygotic conceptions may have either monochorionic or dichorionic placentation, depending
are identical or fraternal. upon the time of division of the zygote. Diamniotic dichorionic placentation occurs with division
Which ultrasound marker is prior to the morula state (within three days post fertilization). Diamniotic monochorionic
suggestive of dizygotic placentation occurs with division between days four and eight post-fertilization. Monoamniotic,
(fraternal) twins? monochorionic placentation occurs with division between days eight and 12 post fertilization.
Division at or after day 13 results in conjoined twins. The ultrasound markers for determination of
A. Increased amniotic fluid chorionicity described above have been used to assess risk for complications of pregnancy, most
volume in one of the twins notably the twin-twin transfusion syndrome.
B. Two separate placentas
(anterior and posterior)
C. Dividing membranes less
than 1 mm
D. Concordant growth of the
twins
E. Twin-twin transfusion
syndrome
159. A 35-year-old woman presents A. Autosomal trisomy is the most common abnormal karyotype encountered in spontaneous
to the emergency department abortuses, accounting for approximately 40-50% of cases. Triploidy accounts for approximately
with heavy vaginal bleeding at 15%, tetraploidy 5% of cases, and Monosomy X (45X, 0) identified in 15-25% of losses. The Fragile X
seven weeks gestation. On mutation involves an expanded number of trinucleotide repeats in the CGG (cytosine-guanine)
examination, she has a dilated sequence.
cervix with blood and tissue
present at the cervical os.
Which of the following is the
most likely chromosomal
abnormality to be found in the
karyotypic evaluation of the
products of conception?

A. Autosomal trisomy
B. Triploidy
C. Tetraploidy
D. Monosomy X (45X,0)
E. Fragile X mutation
160. A 36-year-old female G1 presents for A. When a pregnancy is complicated by fetal growth restriction, various fetal physiologic
her prenatal care visit at 35 weeks parameters require assessment. In growth-restricted pregnancies, oligohydramnios is
gestation. She has good dating criteria frequently found. This finding is presumably due to reduced fetal blood volume, renal
that were confirmed by a first trimester blood flow and urinary output. Chronic hypoxia is responsible for diverting blood flow
ultrasound. Her previous medical from the kidney to organs that are more critical during fetal life. The significance of the
history is positive for hypertension and amniotic fluid volume with respect to fetal outcome has been well documented. Ninety
type 2 diabetes. You have been percent of patients with oligohydramnios delivered growth restricted infants. These
following fetal growth with serial infants experienced a high rate of fetal compromise. The systolic/diastolic (S/D) ratio of
ultrasounds. At this visit, ultrasound the umbilical artery is determined by Doppler ultrasound. An increase in the S/D ratio
reveals limited fetal growth over the reflects increased vascular resistance. It is a common finding in IUGR fetuses. A normal
past three weeks. Biometry is S/D ratio indicates fetal well-being. As vascular resistance increases, the S/D ratio
consistent with 32-5/7, EFW 2175 g, increases. With severe resistance, there is absence and ultimately reversal of end-diastolic
<10th percentile. What is the most flow. These findings are associated with an increased rate of perinatal morbidity and
appropriate next test indicated in the mortality, and a higher likelihood of a long-term poor neurologic outcome. Options for
management of this patient? antenatal testing include the non-stress test, contraction stress test, and the biophysical
A. Amniotic fluid volume, umbilical profile. Any of these may be used in a growth-restricted fetus as a means of detecting
artery Doppler systolic: diastolic ratio, possible or probable fetal asphyxia. While fetal kick counts may be of value, additional
non-stress test fetal testing such as twice weekly NST with AFI and weekly umbilical artery Doppler
B. Daily fetal kick counts with follow up studies is indicated in monitoring fetuses with IUGR.
ultrasound to reassess fetal growth in
one week
C. Amniocentesis for fetal lung maturity
D. Twice daily fetal kick counts with
delivery at 37 weeks gestation
E. None, delivery is indicated
161. A 36-year-old G1 began prenatal care D. There is substantial evidence from experimental animal studies that suggests that
at eight weeks gestation. At that time, alterations in uteroplacental perfusion affect the growth and status of the fetus, as well as
the gestational age was confirmed by a the placenta. This patient has significant medical diseases that are affecting her
transvaginal ultrasound. She is now at vasculature and, ultimately, limiting the substrate availability to the fetus with resultant
36 weeks gestation. Her previous uteroplacental insufficiency. The vascular disease is evidenced by retinopathy and
medical history reveals hypertension proteinuria. The other choices above may all result in fetal growth restriction; however,
for eight years and class F diabetes for they are not the most likely etiology in this clinical scenario.
five years (baseline proteinuria = 1 g).
She smokes one half-pack of cigarettes
per day. On examination at 32 weeks
gestation, her fundal height was 29 cm.
At 33 weeks, biometry was consistent
with 31-3/7, EFW 1827g, 25th percentile.
Today, ultrasound reveals limited fetal
growth over the past three weeks.
Biometry is consistent with 31-5/7, EFW
1900 g, <10th percentile. What is the
most likely etiology of the intrauterine
growth restriction in this case?
A. Genetic factors
B. Congenital anomaly
C. Tobacco use
D. Uteroplacental insufficiency
E. Perinatal infection
162. A 36-year-old G1P0 woman presents in active
labor. Her past medical history and prenatal
course were complicated by chronic
hypertension and superimposed preeclampsia.
She received magnesium sulfate for seizure
prophylaxis and oxytocin augmentation. She
undergoes an uneventful spontaneous vaginal
delivery. Postpartum, she has a 1000 ml
hemorrhage due to uterine atony. Her blood
pressure is 130/80; pulse 96; and she is afebrile.
Which of the following uterotonic agents is
contraindicated in this patient?
A. Oxytocin
B. Methylergonovine
C. Prostaglandin F2-alpha
D. Prostaglandin E2
E. Misoprostol
163. A 36-year-old G1 with type 1 diabetes is
diagnosed with intrauterine growth restriction at
33 weeks gestation. What is the most appropriate
next step in management?
A. Amniocentesis
B. Immediate delivery
C. Weekly ultrasounds to assess fetal growth
D. Antenatal testing of fetal well-being
E. Observation
164. A 36-year-old G2P1 woman presents for her first
prenatal visit at 11 weeks gestation. She has a
two-year history of chronic hypertension treated
with lisinopril and labetalol. In addition, she has
hypothyroidism treated with levothyroxine, and
recurrent herpes, for which she is on chronic
acyclovir suppressive therapy. She takes
amitriptyline for migraine headaches. Which of
her medications is contraindicated in pregnancy?
A. Levothyroxine
B. Labetalol
C. Acyclovir
D. Lisinopril
E. Amitriptyline
B. Methergine, prostaglandins, misoprostol, and oxytocin are all uterotonics
and used to increase uterine contractions and decrease uterine bleeding.
Methylergonovine is an ergot alkaloid, which is a potent smooth muscle
constrictor. It is also a vasoconstrictive agent and should be withheld from
women with hypertension and/or preeclampsia. Misoprostol, prostaglandin E1,
used for cervical ripening and labor induction, is a uterotonic agent frequently
used for uterine atony, although not FDA approved for this use.
D. Once intrauterine growth restriction is detected, the fetus needs to be
evaluated periodically for evidence of well-being until delivery is deemed
necessary. This will result in once or twice weekly testing, depending on the
modality of assessment that is being used. Testing includes: non-stress test
(NST), where the fetal heart beat is recorded over a period of at least 30
minutes while looking for accelerations with fetal movement, and the
biophysical profile, which includes an ultrasound evaluation of fetal movement,
fetal tone, amniotic fluid and breathing. NSTs should be performed twice
weekly with at least a weekly AFI. The BPP may be performed weekly.
Ultrasound for fetal growth is not useful if more frequent than every two weeks.
An amniocentesis for fetal lung maturity can be considered at more advanced
gestational age.
D. Amitriptyline, levothyroxine, labetalol and acyclovir are medications that are
frequently used in pregnancy and are felt to have acceptable safety profiles.
The use of angiotensin converting enzyme inhibitors, such as Lisinopril, beyond
the first trimester of pregnancy has been associated with oligohydramnios, fetal
growth retardation and neonatal renal failure, hypotension, pulmonary
hypoplasia, joint contractures and death. Amitriptyline is used in pregnancy to
treat migraine headaches.
165. A 36-year-old G5P4 woman with no D. Although all the options above can result in third trimester vaginal bleeding, the
prenatal care presented in active labor most likely cause in this patient is placental abruption. This diagnosis goes along with
with a blood pressure of 170/105 and 3+ the tachysystole on tocometer and evidence of fetal anemia (tachycardia and
proteinuria. Fundal height is 28 cm. Fetal sinusoidal heart rate pattern) on the heart rate tracing. Hypertension and preeclampsia
heart tones were found to be in the 170s are risk factors for abruption. She has no history of cervical trauma.
with decreased variability and a
sinusoidal pattern. Resting uterine tone
was noted to be increased and she was
having frequent contractions (every 1-2
minutes). The patient complained of bright
red vaginal bleeding for the past hour.
Based on this history, what is the most
likely etiology of her vaginal bleeding?

A. Uterine rupture
B. Placenta previa
C. Bloody show
D. Abruptio placentae
E. Cervical trauma
166. A 37-year-old G2P1 woman with poorly
controlled chronic hypertension presents
in labor at term. Her prenatal course was
uncomplicated. She delivers a 3500 gram
infant spontaneously after oxytocin
augmentation of labor. Immediately
postpartum, she experiences excessive
bleeding. Her blood pressure is 130/90;
pulse 84; and she is afebrile. On
examination, uterine fundus is firm and
the placenta is intact. Which of the
following is the most appropriate next
step in the management of this patient?
A. After ensuring appropriate backup, establishing intravenous access and stabilizing a
patient as needed, the first steps in the management of postpartum hemorrhage are to
make sure the uterus is well-contracted, there is no retained placental tissue and to
look for lacerations. This patient has a firm fundus, which indicates a contracted uterus.
Her placenta is complete, which typically rules out retained placental tissue, so it is
important to rule out lacerations, which can lead to hemorrhage. Methylergonovine,
prostaglandins and oxytocin are all uterotonics and used to increase uterine
contractions and decrease uterine bleeding. Methylergonovine is an ergot alkaloid,
which is a potent smooth muscle constrictor. It is also a vasoconstrictive agent and
should be withheld from women with hypertension and/or preeclampsia. B Lynch
suture is used at time of laparotomy for uterine atony. Oxytocin should not be given as
an IV push. Uterine artery embolization can be considered after other sources of
bleeding such as lacerations are ruled out.

A. Exploration for lacerations

B. Methylergonovine
C. B Lynch suture
D. IV push of oxytocin
E. Uterine artery embolization
167. A 37-year-old G3P0 woman at 29 weeks
gestation presents with uterine
contractions every five minutes. Her
cervix is 1 cm dilated and 50% effaced.
Fetal fibronectin test is negative. The
patient stops having contractions after
bedrest and hydration. What is the
strength of using a fetal fibronectin test in
patients with preterm contractions?
A. Positive predictive value
B. Negative predictive value
C. High sensitivity
D. Low false positive rate
E. High false positive rate
B. Fibronectin is an extracellular matrix protein that is thought to act as an adhesive
between the fetal membranes and underlying decidua. It is normally found in cervical
secretions in the first half of pregnancy. Its presence in the cervical mucus between 22
and 34 weeks is thought to indicate a disruption or injury to the maternal-fetal
interface. Fetal fibronectin is FDA approved for use in women with symptoms of
preterm labor from 24 to 35 weeks and during routine screening of asymptomatic
patients from 22 to 30 weeks gestation. Fetal fibronectin has a negative predictive
value of 99.2% in symptomatic women 99 out of every 100 patients with a single
negative test result will not deliver in the next 14 days. The positive predictive value in
symptomatic women is 16.7% 17 out of 100 women with a positive test will deliver
within 14 days. In asymptomatic women, a negative fetal fibronectin test has a negative
predictive value of 96.7% for delivery before 35 weeks.
168. A 38-year-old G0 woman
presents for a
preconception evaluation.
She has a history of long-
time anxiety and
depression, and is
interested in continuing her
medications in pregnancy,
which includes sertraline
(Zoloft). She expresses
concern because sertraline
is a Category C drug. Which
of the following
descriptions is associated
with FDA Category C drug
classification?
C. Depression is more common in women than men. Appropriate treatment, including during the
antepartum period, is a component of good medical care. As in all cases, when considering
treatments, the benefits should outweigh the risks. With Category A drugs, there are adequate, well-
controlled studies in pregnant women that have not shown an increased risk of fetal abnormalities to
the fetus in any trimester of pregnancy. With Category B, animal studies have revealed no evidence of
harm to the fetus; however, there are no adequate and well-controlled studies in pregnant women or
animal studies that have shown an adverse effect, but adequate and well-controlled studies in
pregnant women have failed to demonstrate a risk to the fetus in any trimester. Category C drugs
have animal studies that show an adverse effect and there are no adequate and well-controlled
studies in humans, but potential benefits may warrant use of the drug in pregnant women despite
potential risks. Category D drugs have adequate well-controlled or observational studies in pregnant
women and are known risks to the fetus. Category X drugs should not be used in pregnancy, because
adequate well-controlled or observational studies in animals or pregnant women have demonstrated
positive evidence of fetal abnormalities or risks.

A. Studies in humans have

demonstrated fetal
abnormalities and/or there
is positive evidence of
human fetal risk based on
adverse reaction data
B. Positive evidence of
human fetal risk based on
adverse reaction data from
studies in humans
C. Animal reproduction
studies have shown an
adverse effect on the fetus
and there are no adequate
and well controlled studies
in humans
D. There are no adequate
and well controlled studies
in pregnant women; animal
reproduction studies have
failed to demonstrate a risk
in the fetus
E. Adequate, well-
controlled studies in
pregnant women that have
not shown an increased risk
of fetal abnormalities to the
fetus in any trimester of
pregnancy
169. A 38-year-old G2P0 woman at 28 weeks gestation has been
diagnosed with preterm labor and is currently stable on
nifedipine. Her cervical exam has remained unchanged at 2 cm
dilated, 75% effaced and -2 station. Her vital signs are stable and
fetal heart tracing is Category I. You recommend treatment with
betamethasone (a steroid). Which of the following is associated
with betamethasone therapy in the newborn?
A. Enhancement of fetal growth
B. Increased risk of infection
C. Increased incidence of necrotizing enterocolitis
D. Increased incidence of intracerebral hemorrhage
E. Decreased incidence of intracerebral hemorrhage
170. A 38-year-old G4P2 woman was diagnosed with triplets when an
ultrasound was performed at 12 weeks gestational age. Which of
the following is the most concerning complication for this
multiple gestation?
A. Preeclampsia
B. Intrauterine growth restriction
C. Preterm birth
D. Gestational diabetes
E. Abnormal placentation
171. A 38-year-old G5P4 woman with a history of four Cesarean
deliveries is at 36 weeks gestation with a singleton pregnancy.
She presents to labor and delivery with complaints of vaginal
bleeding for the last hour. Prenatal care has been unremarkable
except for a second trimester ultrasound discovering an anterior
placenta, which partially covers the cervical os. Follow up
ultrasound exams have confirmed these findings. The patient
denies uterine contractions and abdominal pain. She feels the
baby moving. Her blood pressure is 110/60; pulse 110; and she is
afebrile. Her abdomen and uterus are non-tender and soft. Fetal
heart tones have a baseline of 140 and are reassuring. This patient
is at greatest risk for which of the following complications?
A. Vasa previa
B. Placenta accreta
C. Placental abruption
D. Uterine rupture
E. Preterm labor
E. Treatment with betamethasone from 24 to 34 weeks
gestation has been shown to increase pulmonary maturity and
reduce the incidence and severity of RDS (respiratory distress
syndrome) in the newborn. It is also associated with decreased
intracerebral hemorrhage and necrotizing enterocolitis in the
newborn. It has not been associated with increased infection
or enhanced growth.
C. Preterm delivery increases the risk of morbidity and
mortality, increasing with higher orders of multiples. Preterm
birth occurs in over 50% of twin pregnancies, 90% of triplet
pregnancies, and almost all quadruplet pregnancies. While all
the choices may occur with a multiple gestation, prematurity
has the most significant consequences as it is associated with
an increased risk of respiratory distress syndrome (RDS),
intracranial hemorrhage, cerebral palsy, blindness, and low
birth weight. Intrauterine growth restriction, intrauterine death
of one or more fetuses, miscarriage and congenital anomalies
are all more common with multiple gestations, as are the
complications of preeclampsia, diabetes and placental
abnormalities.
B. Placenta accreta occurs when the placenta grows into the
myometrium. This patient is at risk for this condition due to her
history of four previous Cesarean deliveries, and the low
anterior placenta. The scar tissue from the previous surgery
prevents proper implantation of the placenta and it
subsequently grows into the muscle. Vasa previa is a rare
condition where the umbilical cord inserts into the membranes.
Placental abruption is the premature separation of the
normally implanted placenta. Risk of uterine rupture could be
as high as 5% in this case, and the risk of placenta accreta with
four prior Cesarean deliveries approaches 50%. The patient is
not experiencing contractions at the present time, so preterm
labor is unlikely.
172. A 39-year-old G1P0 woman at 37 weeks gestation is being
induced secondary to polyhydramnios. She has received
cervical ripening with prostaglandin E2, and is now on
oxytocin. Her cervix on last check was 3cm, 75% effaced, -4
station. Her water just broke, and the nurse reports that the
patient is now contracting every minute and notes that she is
having a large amount of bleeding. On exam, her blood
pressure is 100/80; pulse 100; temperature of 100.0F (37.8C);
and she has a Category II tracing. Her cervical exam is 10cm,
100% effaced, +2 station. Which of the following is the most
likely explanation for her bleeding and labor progression?
A. Oxytocin
B. Rupture of membranes
C. Abruptio placentae
D. Chorioamnionitis
E. Normal labor progression
173. A 39-year-old G4P1 woman at 36 weeks gestation presents to
labor and delivery. Upon initial evaluation, no fetal heart
tones were noted on Doptone. Ultrasound confirms fetal
demise. Problems during the pregnancy include diagnosis of
an open neural tube defect, estimated fetal weight >90th
percentile, polyhydramnios and a nonreactive NST (non-
stress test) the week prior to admission. What is the most
likely etiology of this fetal demise?
A. Uncontrolled hypertension
B. In-utero viral infection
C. Antiphospholipid antibody syndrome (APAS)
D. Uncontrolled diabetes
E. Untreated maternal hypothyroidism
174. A 40-year-old G1P0 woman at 22 weeks gestation presents to
the office with a complaint of pelvic pressure. She reports
that she had intercourse the night prior to presentation and
noted some mucous mixed with blood this morning. Her
history is significant for type 1 diabetes and she is on an
insulin pump. Her surgical history is significant for a history of
cone biopsy for treatment of abnormal Pap smear three
years ago. On examination, her BMI is 26. She is noted to have
a 2 cm dilated cervix with bulging membranes that rupture
upon placing the speculum. Fetal parts are noted in the
vagina. What is the most likely cause of this finding?
A. Uncontrolled diabetes
B. Cervical incompetence/insufficiency
C. Preterm labor
D. Advanced maternal age
E. Infection
C. This patient likely is experiencing a placenta abruption. Her
biggest risk factor is polyhydramnios with rapid decompression of
the intrauterine cavity. While oxytocin is used to augment labor, in a
nulliparous patient, the difference between her two exams is
extreme. Typically, normal labor progresses about 1 cm per hour in
the active phase of labor (multiparous woman about 1-2 cm/hour).
While there may be some vaginal bleeding (bloody show, or light
bleeding with cervical dilation) it is not normal to have a large
amount of bleeding. This patient has no signs or symptoms of
chorioamnionitis.
D. Uncontrolled diabetes during organogenesis is associated with a
high rate of birth defects. The most common sites affected are the
spine and the heart of the fetus, although all birth defects are
increased. Fetuses in utero exposed to high levels of glucose
transplacentally have increased growth and polyuria resulting in an
increase in the amniotic fluid. While some viral infections are also
associated with placentomegaly and polyhydramnios, the fetus will
have normal or decreased growth depending on the timing of the
infection. Severe hypertension and active APAS is often associated
with oligohydramnios and intrauterine growth restriction. The risk of
miscarriage is increased if hypothyroidism goes untreated.
B. The most likely cause of painless cervical dilation which leads to
pelvic pressure, bulging membranes and fetal loss is cervical
incompetence or insufficiency. This patient has a history of cone
biopsy which can lead to cervical incompetence. Preterm labor by
definition does not occur until 24 weeks gestation. Although
uncontrolled diabetes can lead to fetal malformations and early
miscarriage, it is not typically a cause of fetal loss in the second
trimester. Advanced maternal age is associated with an increased
risk of stillbirth, preeclampsia, gestational diabetes and intrauterine
growth restriction.
175. A 40-year-old G1P0 woman at 34 3/7 weeks gestation was found on
the floor at work having a grand mal seizure. Her airway was secured.
Blood pressure in the ambulance was 140/90. What is the initial
treatment for her condition?
A. Magnesium sulfate
B. Valium
C. Hydantoin
D. Phenobarbital
E. Naloxone
176. A 40-year-old G6P5 woman delivered a 5020 grams live born male
infant vaginally 20 minutes ago. The nurse notes that the patient is
having ongoing bleeding that she estimates to be 1000 cc. Her past
medical history is significant for chronic hypertension and asthma. She
has received oxytocin and misoprostol. Her examination reveals a
boggy uterus. Which of the following is the next step in management
of her bleeding?
A. Uterine artery embolization
B. B-Lynch compression stitch
C. Bakri balloon placement
D. Uterine artery ligation
E. Hysterectomy
177. A 41-year-old G3P2 woman presents with cramping, vaginal bleeding
and right lower quadrant pain for five days which has progressively
worsened. Her last normal menstrual period occurred seven weeks
ago. Her surgical history is notable for a bilateral tubal ligation
following her last delivery. On physical exam, vital signs are: blood
pressure 110/74; pulse 82; respirations 18; temperature 98.6F (37.0C).
On abdominal exam, she has right lower quadrant tenderness, with
rebound and bilateral guarding in the lower quadrants. On pelvic
exam, she has scant old blood in the vagina and a normal appearing
cervix. Her uterus is normal size and slightly tender. She has cervical
motion tenderness on bimanual examination, and marked tenderness
on rectal examination. Her quantitative Beta-hCG is 4000 mIU/ml;
progesterone 6.2 ng/ml; hematocrit 34%; and WBC 15,400/mcL, with
88% segmented neutrophils and no bands. The transvaginal ultrasound
shows an empty uterus with endometrial thickening, a mass in right
ovary measuring 3.8 x 2 cm, and a small amount of free fluid in the
pelvis. What is the most likely diagnosis in this patient?
A. Pelvic inflammatory disease
B. Ectopic pregnancy
C. Heterotopic pregnancy
D. Missed abortion
E. Ruptured corpus luteum cyst
A. Magnesium sulfate is the treatment of choice for
eclampsia, which is her most likely diagnosis. Valium,
hydantoin, tiagabine, and barbiturates can also be used to
treat seizures, but are not first-line therapy for eclampsia.
They can be added as second agents, or used if
magnesium is contraindicated. Naloxone (Narcan) is a
drug used to counter the effects of opioid overdose, for
example heroin or morphine overdose, and is specifically
used to counteract life-threatening depression of the
central nervous system.
C. This patient has uterine atony, which accounts for about
80-90% of all postpartum hemorrhages. Risk factors for
PPH include uterine over distension (polyhydramnios,
macrosomia, and multiple gestation), prolonged labor,
chorioamnionitis, and grandmultiparity. This patient has
already received uterotonic agents and while additional
agents are available, because of her hypertension and
asthma both methergine and prostaglandin F2 alpha are
contraindicated. All of the choices listed are treatments,
the least invasive treatment is placement of the Bakri
balloon, which is a device placed into the uterus with a
balloon that is filled with up to 500 cc of sterile fluid. This
places pressure on the inside of the uterus. Uterine artery
ligation, B-lynch compression stitch and hysterectomy all
require a laparotomy and should be reserved for
recalcitrant cases. Uterine artery embolization requires
placement of embolization catheters as well as
interventional radiology.
B. The diagnosis of ectopic pregnancy is made when
either: 1) a fetal pole is visualized outside the uterus on
ultrasound; 2) the patient has a Beta-hCG level over the
discriminatory zone (the level at which an intrauterine
pregnancy should be seen on ultrasound, usually 2000
mIU/ml) and there is no intrauterine pregnancy (IUP) seen
on ultrasound; or 3) the patient has inappropriately rising
Beta-hCG level (less than 50% increase in 48 hours) and
has levels which do not fall following diagnostic dilation
and curettage. This patient meets criteria #2, as her Beta-
hCG is >2000 mIU/ml with no intrauterine pregnancy seen
on ultrasound. The history, physical exam and lab data are
not consistent with pelvic inflammatory disease, ovarian
torsion, appendicitis or a ruptured corpus luteum cyst.
With a heterotopic pregnancy, there should be a visible
pregnancy in the uterus. With a missed abortion there
should also be some visible tissue or a fetal pole within
the uterus.
178. A 42-year-old G5P2 woman at 36 weeks gestation is diagnosed with
preeclampsia. Her previous pregnancy was complicated by twins and
preeclampsia at 36 weeks gestation. She also has had two spontaneous
abortions at seven weeks gestation. Which of the following conditions is
not associated with her increased risk for preeclampsia in this
pregnancy?
A. Previous history of preeclampsia
B. Chronic hypertension
C. Multifetal pregnancy
D. Age
E. Previous spontaneous abortion
179. A 45-year-old G4P3 woman presents with vaginal bleeding. Last week,
she performed a home pregnancy test that was positive. She thinks her
last menstrual period was four months ago. The last time she saw her
doctor was eight years ago, with the birth of her last child. She has no
serious medical problems, has smoked a pack of cigarettes a day since
the age of 20, occasionally has a beer and does not exercise.
Abdominal examination reveals a soft abdomen and the fundus
palpable just below the umbilicus. Pelvic ultrasound reveals a fundal
placenta and a fetus measuring 18 weeks with normal cardiac activity.
Vaginal examination reveals a 3-centimeter lesion on the posterior lip
of the cervix. It easily bleeds with palpation and is hard in consistency.
Which of the following is the most likely cause of the bleeding?
A. Cervicitis
B. Cervical polyp
C. Endometrial polyp
D. Cervical cancer
E. Nabothian cyst
180. Thirty-six hours ago a 23-year-old G1P1 woman delivered vaginally and
sustained a 2nd-degree laceration. She had a prolonged first stage of
labor, ruptured membranes for 26 hours and received penicillin for
group B Strep prophylaxis. She now complains of increasing abdominal
pain, cramping and heavy, foul-smelling lochia. Her vital signs reveal a
temperature of 100.0 F (37.8 C); pulse 80; blood pressure 120/60; and
respirations 18. She has a tender uterine fundus that measures at the
umbilicus. Her extremities reveal mild bilateral edema; no erythema or
tenderness. Blood work reveals a white count of 12.2; hematocrit of 34%;
and normal chemistries. Her urinalysis is positive for blood and
negative for WBCs, leukocyte esterase and nitrites. In addition to
ampicillin, which of the following would be the best antibiotic choice?
A. Erythromycin
B. Gentamicin
C. Doxycycline
D. Vancomycin
E. Ciprofloxacin
E. The previous history of spontaneous abortion does
not put the patient at increased risk. The incidence of
preeclampsia is commonly cited to be about 5 percent
and is markedly influenced by parity. It is related to race,
ethnicity and genetic predisposition. Environmental
factors are also likely to play a role. Other risk factors
for preeclampsia include a previous history of the
disease, chronic hypertension, multifetal pregnancy and
molar pregnancy. In addition, patients at extremes of
maternal age or with diabetes, chronic renal disease,
antiphospholipid antibody syndrome, vascular or
connective tissue disease or triploidy are at increased
risk for developing preeclampsia
D. Cervical cancer can unfortunately complicate
pregnancies and presents with bleeding. She is at risk
due to lack of screening as well as her history of
smoking. Other causes of bleeding need to be ruled out
such as cervical incompetence, infection or trauma.
Treatment for cervical cancer during pregnancy requires
difficult decisions that consider the stage of cancer,
appropriate therapy, maternal welfare and fetal welfare.
Cervical polyps occur during pregnancy and can be a
cause of bleeding, but are typically soft and not hard or
nodular on examination. Nabothian cysts are very
common, but do not typically cause bleeding.
B. Endomyometritis is a common complication of
prolonged labor, prolonged rupture of membranes and
multiple vaginal examinations. The infection is
polymicrobial, mostly anaerobic and requires broad-
spectrum antibiotics for treatment until the patient is
afebrile for 24 hours. By adding Gentamicin, you are
covering the spectrum of gram-negative organisms.
Erythromycin provides good coverage for upper
respiratory infections. Vancomycin provides good
coverage for S. aureus and penicillin-resistant gram-
positive bacteria. Ciprofloxacin provides excellent
coverage for gram-negative pathogens, including
Pseudomonas.
 Unit 3: Gynecology
Study online at quizlet.com/_2io49q

1. A 12-year-old girl is brought to the office by C. The division of interests based on gender is inappropriate. Children should be
her mother who complains that her encouraged to follow their own interests and desires. The girl has a normal physical
daughter has never been interested in dolls exam; therefore, diagnostic studies are not indicated.
and pretty dresses, but prefers to play with
tools and mechanical things. The mother
also divulges that her brother is gay and is
worried that her daughter will grow up as a
lesbian and be stigmatized. A private
conversation with the girl reveals that she is
starting to show an interest in boys, and
even has a "boyfriend." Examination reveals
a normal pre-pubertal phenotype. Which of
the following is the most appropriate course
of action at this time?
A. Encourage mother to support more
gender-appropriate activities including
dressing like and playing with other girls
B. Refer the mother to a family counselor
C. Reassure the mother that her daughter's
behavior is normal
D. Inform mother that her daughter may
ultimately develop an alternative sexual
lifestyle
E. Have the patient return for a repeat
assessment once she has begun menarche
2. A 16-year-old G0 female presents to the D. Although some patients can be treated with an outpatient regimen, this patient
emergency department with a two-day should be hospitalized for IV treatment, as she has nausea and vomiting so she might
history of abdominal pain, nausea and not be able to tolerate oral medications. While adolescents have no better outcomes
vomiting. She is sexually active with a new from inpatient vs outpatient therapy, each patient should be assessed for compliance.
partner and is not using any form of It is important to treat aggressively in order to prevent the long-term sequelae of
contraception. On examination, her acute salpingitis. You would not wait for culture results before initiating treatment. Her
temperature is 100.2F (37.9C), and she has recent sexual contacts should also be informed (by her and/or with her consent) and
bilateral lower quadrant pain, with slight treated. According to the 2010 CDC treatment guidelines, there are two options for
rebound and guarding. On pelvic parenteral antibiotics covering both gonorrhea and chlamydia. Cefotetan or cefoxitin
examination, she has purulent cervical PLUS doxycycline or clindamycin PLUS gentamicin. For outpatient treatment, the 2010
discharge and cervical motion tenderness. CDC guidelines recommend ceftriaxone, cefoxitin, or other third-generation
Her white count is 14,000/mcL. What is the cephalosporin (such as ceftizoxime or cefotaxime) PLUS doxycycline WITH or
most appropriate next step in the WITHOUT metronidazole. There are alternative oral regimens as well.
management of this patient? http://www.cdc.gov/std/treatment/2010/pid.htm

A. Oral amoxicillin clavunate and

doxycycline
B. Oral metronidazole and doxycycline
C. IV metronidazole and doxycycline
D. IV cefotetan and doxycycline
E. No treatment until culture results are
back
3. A 16-year-old G0 female presents to the emergency E. The signs and symptoms of acute salpingitis can vary and be very
department with a two-day history of abdominal pain. subtle with mild pain and tenderness, or the patient can present in much
She is sexually active with a new partner and is not more dramatic fashion with high fever, mucopurulent cervical discharge
using any form of contraception. Temperature is 101.8F and severe pain. Important diagnostic criteria include lower abdominal
(38.8C). On examination, she has lower abdominal tenderness, uterine/adnexal tenderness and mucopurulent cervicitis.
tenderness and guarding. On pelvic exam, she has
diffuse tenderness over the uterus and bilateral adnexal
tenderness. Beta-hCG is <5. What is the most likely
diagnosis for this patient?

A. Ectopic pregnancy
B. Appendicitis
C. Acute cystitis
D. Endometriosis
E. Acute salpingitis
4. A 16-year-old girl is brought by her mother to her A. It is not appropriate to discuss the daughter's sexuality with her mother,
primary care physician requesting that her daughter although her mother has the right to know about her daughter's overall
have a gynecological examination. She is fearful that her health as her legal guardian. The daughter should be encouraged to have
daughter is sexually active. A private conversation with an open conversation with her mother, but that this is entirely up to her
the girl reveals that she is sexually active and is on oral discretion and that she will be supported in whatever decision she
contraceptives prescribed by a community clinic. Having ultimately makes about disclosing her sexual activity.
seen what her older sister went through when she
became sexually active, she prefers not to tell her
mother about her sexual activity for fear of severe
punishment. The pelvic examination is normal. Which is
the most appropriate action at this time?
A. Tell the mother that her daughter is healthy
B. Insist to the daughter that she disclose her sexual
activity to her mother
C. Reassure the mother that her daughter's sexual
activity is a normal activity for most girls her age
D. Speak to the mother openly about her daughter's
condition
E. Disclosure of any medical information is forbidden
and a major HIPPA violation
5. A 17-year-old G0 female presents with a three-year C. Chronic pelvic pain is the indication for at least 40% of all gynecologic
history of severe dysmenorrhea shortly after menarche laparoscopies. Endometriosis and adhesions account for more than 90%
at age 14. Her menstrual cycles are regular with heavy of the diagnoses in women with discernible laparoscopic abnormalities,
flow. She has been treated with ibuprofen and oral and laparoscopy is indicated in women thought to have either of these
contraceptives for the last year without significant conditions. Often, adolescents are excluded from laparoscopic evaluation
improvement. She misses 2-3 days of school each month on the basis of their age, but several series show that endometriosis is as
due to her menses. She has never been sexually active. common in adolescents with chronic pelvic pain as in the general
Physical examination is remarkable for Tanner Stage IV population. Therefore, laparoscopic evaluation of chronic pelvic pain in
breasts and pubic hair. Pelvic examination is normal, as adolescents should not be deferred based on age. Laparoscopy can be
is a pelvic ultrasound. Both the patient and her mother both diagnostic and therapeutic in this patient in whom you suspect
are concerned. What is the next best step in the endometriosis. None of the other imaging modalities listed will help in the
management of this patient? further workup of this patient.

A. Sonohysterogram
B. CT scan of the pelvis
C. Diagnostic laparoscopy
D. MRI of the pelvis
E. Hysterosalpingogram
6. A 17-year-old G0 sexually active female presents to the
emergency department with pelvic pain that began 24 hours
ago. She reports menarche at the age of 15 and coitarche soon
thereafter. She has had four male partners, including her new
boyfriend of a few weeks. Her blood pressure is 100/60; pulse
100; and temperature 102.0F (38.9C). On speculum
examination, you note a foul-smelling mucopurulent discharge
from her cervical os and she has significant tenderness with
manipulation of her uterus. What is the next best step in the
management of this patient?
E. The most likely cause of the symptoms and signs in this patient
is infection with a sexually transmitted organism. The most likely
organisms are both N. gonorrhoeae and chlamydia, and the
patient should be treated empirically for both after appropriate
blood and cervical cultures are obtained. There is no evidence
that adolescents have better outcomes from inpatient therapy.
However, since the patient also has a high fever, inpatient
admission is recommended for aggressive intravenous antibiotic
therapy in an effort to prevent scarring of her fallopian tubes and
possible future infertility.

A. Outpatient treatment with oral broad spectrum antibiotics

B. Outpatient treatment with intramuscular and oral broad
spectrum antibiotics
C. Intravenous antibiotics and dilation and curettage
D. Inpatient treatment, laparoscopy with pelvic lavage
E. Inpatient treatment and intravenous antibiotics
7. A 19-year-old G0 woman presents to the office with a two-week D. Mildly symptomatic or asymptomatic urinary tract infections are
history of low pelvic pain and cramping. She has a new sexual common in female patients. Urinary tract infection must be
partner and is on oral contraception and uses condoms. She is considered in patients who present with low pelvic pain, urinary
one week into her cycle. She has noted no vaginal discharge, frequency, urinary urgency, hematuria or new issues with
itch or odor. She denies fevers or chills. She does note that she incontinence. While yearly screening for chlamydia is
is on a new diet and has started drinking lots of water. As such, recommended for patients less than 25 years old, this patient's
she notes that she is urinating much more frequently. Her symptoms are most consistent with a UTI. A pelvic ultrasound is
examination is entirely unremarkable. Which of the following is not indicated at this point.
the most appropriate next step in the management of this
patient?

A. Pelvic ultrasound
B. Pap test
C. Wet prep
D. Urinalysis
. Testing for chlamydia
8. A 20-year-old G0 college student presents with a one-
month history of profuse vaginal discharge and mid-cycle
vaginal spotting. She uses oral contraceptives and she
thinks her irregular bleeding is due to the pill. She is
sexually active and has had a new partner within the past
three months. She reports no fevers or lower abdominal
pain. She has otherwise been healthy. On pelvic
examination, a thick yellow endocervical discharge is
noted. Saline microscopy reveals multiple white blood
cells, but no clue cells or trichomonads. Potassium
hydroxide testing is negative. Vaginal pH is 4.0. No cervical
motion tenderness or uterine/adnexal tenderness is
present. Testing for gonorrhea and chlamydia is
performed, but those results will not be available for
several days and the student will be leaving for Europe
tomorrow. Which of the following is the most appropriate
treatment for this patient?
A. Metronidazole and erythromycin
B. Ceftriaxone and azithromycin
C. Ampicillin and doxycycline
D. Azithromycin and doxycycline
E. No treatment is necessary until all tests results are
known
9. A 20-year-old G2P2 healthy woman presents for her post-
partum check six weeks after a full term normal
spontaneous delivery. She has a 13 month old in addition
to the six-week newborn, and is already feeling
overwhelmed. She desires a reliable form of
contraception. On exam, her vital signs are normal. BMI is
27. The remainder of the exam is unremarkable. Of the
following, what is the most effective and appropriate form
of contraception for this patient?
A. Intrauterine device
B. Tubal ligation
C. Depo-Provera
D. Oral contraceptive pills
E. Essure
B. Mucopurulent cervicitis (MPC) is characterized by a mucopurulent
exudate visible in the endocervical canal or in an endocervical swab
specimen. MPC is typically asymptomatic, but some women have an
abnormal discharge or abnormal vaginal bleeding. MPC can be caused
by Chlamydia trachomatis or Neisseria gonorrhoeae; however, in most
cases neither organism can be isolated. Patients with MPC should be
tested for both of these organisms. The results of sensitive tests for C.
trachomatis or N. gonorrhoeae (e.g. culture or nucleic acid
amplification tests) should determine the need for treatment, unless the
likelihood of infection with either organism is high or the patient is
unlikely to return for treatment. Antimicrobial therapy should include
coverage for both organisms, such as azithromycin or doxycycline for
chlamydia and a cephalosporin or quinolone for gonorrhea.
Uncomplicated cervicitis, as in this patient, would require only 125 mg
of Ceftriaxone in a single dose. Ceftriaxone 250 mg is necessary for the
treatment of upper genital tract infection or pelvic inflammatory
disease (PID).
A. Long-acting reversible contraceptives (LARC) methods such as
contraceptive implants and intrauterine devices are a good option for
this patient. Despite high up-front costs and the need for office visits
for insertion and removal, LARC methods provide many distinct
advantages over other contraceptive methods as Depo-Provera and
oral contraceptives. While Depo-Provera is an effective form of
contraception, it may not be the best choice in this woman with a high
BMI. For this young mother who desires a reversible, but reliable form
of contraception, the high effectiveness, continuation rate and user
satisfaction of LARC methods would be of most benefit. Emerging
evidence indicates that increasing the use of LARC methods also could
reduce repeat pregnancy among adolescent mothers and repeat
abortions among women seeking induced abortion. ("Increasing Use of
Contraceptive Implants and Intrauterine Devices To Reduce
Unintended Pregnancy," ACOG Committee Opinion, No. 450, 2009).
Tubal ligation and Essure are permanent and are not appropriate for
this patient.
10. A 22-year-old G0 woman presents with worsening
pelvic pain. She previously underwent a laparoscopic
ablation of endometriosis followed by continuous oral
contraceptive pills. She had short-term relief from this
approach, but now has failed this treatment and is
seeking additional medical management. Which of
the following mechanisms best explains how a
gonadotropin releasing hormone (GnRH) agonist
would help alleviate her symptoms?
A. Down-regulation of the hypothalamic-pituitary
gland production
B. Up-regulation of the hypothalamic-pituitary gland
production
C. Suppression of both LH and FSH mid-cycle surges
D. Induction of a pseudopregnancy state
E. Competitive inhibitor for estrogen receptors
11. A 23-year-old G0 woman comes to the office to
discuss contraception. Her past medical history is
remarkable for hypothyroidism and mild
hypertension. She has a history of slightly irregular
menses. Her best friend recently got a "patch," so she
is interested in using a transdermal system (patch).
Her vital signs are: blood pressure 130/84; weight 210
pounds; height 5 feet 4 inches. What is the most
compelling reason for her to use a different method
of contraception?
A. Gonadotropin-releasing hormone (GnRH) agonists are analogues of
naturally occurring gonadotropin-releasing hormones that down-regulate
hypothalamic-pituitary gland production and the release of luteinizing
hormone and follicle-stimulating hormone leading to dramatic reductions in
estradiol level. Numerous clinical trials show GnRH agonists are more
effective than placebo and as effective as Danazol in relieving
endometriosis-associated pelvic pain. Danazol, a 17-alpha-ethinyl
testosterone derivative, suppresses the mid-cycle surges of LH and FSH.
Combined estrogen and progestin therapy in oral contraceptives produces
the pseudopregnancy state.
C. The patch has comparable efficiency to the pill in comparative clinical
trials, although it has more consistent use. It has a significantly higher failure
rate when used in women who weigh more than 198 pounds. The patch is a
transdermal system that is placed on a woman's upper arm or torso (except
breasts). The patch (Ortho Evra) slowly releases ethinyl estradiol and
norelgestromin, which establishes steady serum levels for seven days. A
woman should apply one patch in a different area each week for three
weeks, then have a patch-free week, during which time she will have a
withdrawal bleed.

A. Age
B. Hypothyroidism
C. Weight
D. Unpredictable periods
E. Her blood pressure
12. A 23-year-old G0 woman with last menstrual period
14 days ago presents to the office because she had
unprotected intercourse the night before. She does
not desire pregnancy at this time and is requesting
contraception. She has no medical problems and is
not taking any medications. In addition to offering her
counseling and testing for sexually transmitted
infections, which of the following is the most
appropriate next step in the management of this
patient?
E. Emergency contraceptive pills are not an abortifacient, and they have not
been shown to cause any teratogenic effect if inadvertently administered
during pregnancy. They are more effective the sooner they are taken after
unprotected intercourse, and it is recommended that they be started within
72 hours, and no later than 120 hours. Plan B, the levonorgestrel pills, can
be taken in one or two doses and cause few side effects. Emergency
contraceptive pills may be used anytime during a woman's cycle, but may
impact the next cycle, which can be earlier or later with bleeding ranging
from light, to normal, to heavy.

A. Observation for two weeks to establish if

pregnancy occurred before initiating treatment
B. Oral contraceptives now
C. Oral contraceptives after her next normal
menstrual period
D. Emergency contraception and follow-up after next
menstrual period
E. Provide emergency contraception, then begin oral
contraceptives immediately
13. A 23-year-old G1P0 woman at 10 weeks
gestation presents with an intrauterine
embryonic demise. On exam, her blood
pressure is 120/80; heart rate is 67; and she is
afebrile. Her cervix is closed and there is no
evidence of bleeding. She desires to have the
most minimally invasive treatment as
possible. Which of the following options is
best for this patient?
A. Dilation and curettage
B. Manual vacuum aspiration
C. Mifepristone
D. Misoprostol
E. Oxytocin
14. A 23-year-old G1P0 woman at six weeks
gestation undergoes a medical termination of
pregnancy. One day later, she presents to the
emergency department with bleeding and
soaking more than a pad per hour for the last
five hours. Her blood pressure on arrival is
110/60; heart rate 86. On exam, her cervix is 1
cm dilated with active bleeding. Hematocrit
on arrival is 29%. Which of the following is the
most appropriate next step in the
management of this patient?
D. This patient has a missed abortion. Expectant management is the least invasive
treatment. Of the options listed, Misoprostol (prostaglandin E1) is the least invasive
best option for this patient. Misoprostol can be administered orally or vaginally and
will induce uterine cramping with expulsion of products of conception. Potential risk
factors of use include hemorrhage as well as failure. Dilation and curettage and
manual vacuum aspiration are effective methods for treatment of a missed abortion,
but are invasive procedures. Mifepristone, a progesterone receptor blocker, is used
for pregnancy termination. It is recommended for use within 49 days of the last
menstrual period, but there is data to show that it can be effective up to nine weeks.
Oxytocin would not be effective as there has not been up-regulation of receptors at
this gestational age.
E. This patient is having heavy bleeding as a complication of medical termination of
pregnancy. The most likely etiology for her bleeding is retained products of
conception. This is managed best by performing a dilation and curettage. It is not
appropriate to wait six hours before making a decision regarding next step in
management, or to just admit her for observation. Since the patient is not
symptomatic from her anemia, it is not necessary to transfuse her at this time.

A. Admit for observation

B. Repeat hematocrit in six hours
C. Begin transfusion with O-negative blood
D. Give an additional dose of prostaglandins
E. Perform a dilation and curettage
15. A 23-year-old G1 woman with six weeks D. The management of septic abortion includes broad-spectrum antibiotics and
amenorrhea presents with lower abdominal uterine evacuation. Single agent antimicrobials do not provide adequate coverage
pain and vaginal bleeding. Her temperature is for the array of organisms that may be involved and therefore are not indicated. A
102.0F (38.9C) and the cervix is 1 cm dilated. laparoscopy can be indicated if ectopic pregnancy is suspected, but it is unlikely in
Uterus is eight-week size, tender and there this case. Medical termination is not the best option since prompt evacuation of the
are no adnexal masses. Urine pregnancy test uterus is indicated for septic abortion.
is positive. Which of the following is the most
appropriate next step in the management of
this patient?

A. Observation
B. Single-agent antibiotics
C. Medical termination of pregnancy plus
antibiotics
D. Uterine evacuation plus antibiotics
E. Laparoscopy plus antibiotics
16. A 23-year-old G2P1 woman with six weeks amenorrhea D. The patient has a septic abortion. She has fever and bleeding
presents with lower abdominal pain and vaginal bleeding. Her with a dilated cervix which are findings seen with septic abortion.
temperature is 102.0F (38.9C) and the cervix is 1 cm dilated. Threatened abortions clinically have vaginal bleeding, a positive
Uterus is eight-week size and tender. There are no adnexal pregnancy test and a cervical os closed or uneffaced. Missed
masses. Urine pregnancy test is positive. What is the most abortions have retention of a nonviable intrauterine pregnancy for
likely diagnosis? an extended period of time (i.e. dead embryo or blighted ovum). A
normal pregnancy would have a closed cervix. Ectopic pregnancy
A. Threatened abortion would likely present with bleeding, abdominal pain, possibly have
B. Missed abortion an adnexal mass, and the cervix would typically be closed.
C. Normal pregnancy
D. Septic abortion
E. Ectopic Pregnancy
17. A 23-year-old nulliparous woman presents with a painful B. This is a typical presentation for folliculitis which can occur with
nodule in her axilla for three days. She is healthy and has no shaving the axillary hair. Paget's disease is a malignant condition of
personal or family history of breast disease. On exam, no the breast that has the appearance of eczema and does not
abnormalities are seen on inspection and no breast mass is typically present in the axillary area. Fibroadenomas are common
palpated. In the axillary area, shaved skin is noted and an and are usually firm, painless and freely movable. A supernumerary
erythematous raised 1 cm lesion is palpated and is slightly nipple is a congenital variation and is typically located in the nipple
tender to touch. What is the most likely diagnosis? line and not tender. A clogged milk duct can be present in the
axillary region, but it is typically present in a woman who is
A. Paget's disease breastfeeding.
B. Folliculitis
C. Fibroadenoma
D. Supernumerary nipple
E. Duct obstruction
18. A 23-year-old woman presents with complaints of a bilateral D. She's young, likely not to be breast cancer.
nipple itchy sensation for six months. There is no nipple
discharge or dry skin. She reports her nipple appears to be
swollen at times and there is an erythematous fine rash. She
had breast implants placed five years ago, but otherwise has
no significant medical problems or surgical history. What is
the most likely cause of her symptoms?

A. Fibroadenoma
B. Breast cancer
C. Rupture of breast implants
D. Chemical irritants
E. Mastitis
19. A 24-year-old G0 woman presents with a one-year history of
introital and deep thrust dyspareunia. She has a two-year
history of severe dysmenorrhea, despite the use of oral
contraceptives. She also reports significant urinary frequency,
urgency, and nocturia. A recent urine culture was negative.
She underwent a diagnostic laparoscopy six months ago that
showed minimal endometriosis with small implants in the
posterior cul de sac only, which were ablated with a CO2 laser.
What is the most likely diagnosis in this patient?
B. Interstitial cystitis (IC) is a chronic inflammatory condition of the
bladder, which is clinically characterized by recurrent irritative
voiding symptoms of urgency and frequency, in the absence of
objective evidence of another disease that could cause the
symptoms. Pelvic pain is reported by up to 70% of women with IC
and, occasionally, it is the presenting symptom or chief complaint.
Women may also experience dyspareunia. The specific etiology is
unknown, but IC may have an autoimmune and even hereditary
component.

A. Acute cystitis
B. Interstitial cystitis
C. Acute urethral syndrome
D. Acute urethritis
E. Salpingitis
20. A 24-year-old G1P1 woman comes to the office
requesting contraception. Her past medical history is
unremarkable, except for a family history of ovarian
cancer. She denies alcohol, smoking and recreational
drug use. She is in a monogamous relationship. She
wants to decrease her risk of gynecological cancer. Of
the following, what is the best method of contraception
for this patient?
A. Diaphragms
B. Condoms
C. Copper containing intrauterine device
D. Progesterone containing intrauterine device
E. Combined oral contraceptives
21. A 24-year-old G2P2 woman with a history of two prior
Cesarean deliveries desires a tubal ligation for
permanent sterilization. She has two daughters, who
are 3 and 1 years old. She is very sure she does not
desire any more children. She is happily married and is
a stay-at-home-mom. What is the strongest predictor
of post-sterilization regret for this patient?
A. Not working outside the home
B. Parity
C. Marital status
D. Age
E. Children's gender
22. A 24-year-old woman complains of cyclic mastalgia
since the onset of her period at age 12. The symptoms
have increased over the years but were less
troublesome when she took oral contraceptives a few
years ago. Currently, she takes no medications and is
not sexually active. She is a strict vegetarian and eats
soy products. She does not smoke and she drinks a
glass of wine three times a week, and several diet colas
every day. Her mother was diagnosed with breast
cancer at age 55. Her breast exam is normal, except for
some mild fibrocystic changes. Which of the following
elements in her history contributes to her increasing
pain?
A. Alcohol intake
B. Vegetarian diet
C. Family history of breast cancer
D. Caffeine intake
E. Age at menarche
E. Oral contraceptives will decrease a woman's risk of developing ovarian
and endometrial cancer. The first developed higher dose oral
contraceptive pills have been linked to a slight increase in breast cancer,
but not the most recent (current) lower dose pills. Women who use oral
contraceptive pills have a slightly higher risk of developing cervical
intraepithelial neoplasia, but their risk of developing PID, endometriosis,
benign breast changes and ectopic pregnancy are reduced. Both
hypertension and thromboembolic disorders can be a potential side
effect from using oral contraceptive pills. Diaphragms, condoms and
intrauterine devices will not lower her risk of ovarian cancer. The
progesterone IUD may decrease a woman's risk for endometrial cancer
but would not effect her risk for ovarian cancer, and have been associated
with increased ovarian cysts.
D. Approximately 10% of women who have been sterilized regret having
had the procedure with the strongest predictor of regret being
undergoing the procedure at a young age. The percentage expressing
regret was 20% for women less than 30 years old at the time of
sterilization. For those under age 25, the rate was as high as 40%. The
regret rate was also high for women who were not married at the time of
their tubal ligation, when tubal ligation was performed less than a year
after delivery, and if there was conflict between the woman and her
partner.
D. Fibrocystic breast changes are the most common type of benign breast
conditions and occur most often during the reproductive years.
Fibrocystic disease is often associated with cyclic mastalgia, possibly
related to a pronounced hormonal response. Caffeine intake can increase
the pain associated with fibrocystic breast changes, so recommending
that she decrease her caffeine intake may be helpful. Pain is not related to
alcohol intake, her vegetarian diet or age of menarche. There is an
increased risk of breast cancer when atypia is present.q
23. A 25-year-old G1P0 woman at six weeks gestation
comes to the office because of undesired pregnancy.
You discuss with her the risks and benefits of surgical
versus medical abortion using misoprostol and
mifepristone. Compared to surgical abortion, which of
the following is increased in a woman undergoing a
medical abortion?
A. Post abortion pain
B. Lower failure rate
C. Long-term psychological sequelae
D. Blood loss
E. Future infertility
24. A 25-year-old G1P1 woman comes to the office due to
left breast pain and fever. She is breastfeeding her 2
-week-old infant. The symptoms began earlier in the
day and are not relieved by acetaminophen. Her vital
signs are: blood pressure 120/60; pulse 64;
temperature 99.9 F (37.7 C). On exam, she has
erythema on the upper outer quadrant of the left
breast which is tender to touch. There are no palpable
masses. In addition to starting oral antibiotics, what is
the most appropriate next step in the management of
this patient?
A. Discontinue breastfeeding
B. Begin ibuprofen
C. Obtain a breast ultrasound
D. Use a topical antifungal
E. Apply breast binders
25. A 25-year-old G1P1 woman presents with complaints
of a white, watery nipple discharge for four months.
She discontinued breastfeeding six months ago. She
has been told in the past she had fibrocystic breast
changes, but otherwise has no significant medical
problems or surgical history. A white nipple discharge
is noted on manual expression, but the exam is
otherwise normal. She was then sent for a serum
prolactin level which was 45 ng/ml (normal below 40
ng/ml). What is the most appropriate next step in the
management of this patient?
A. Obtain a brain MRI
B. Obtain a beta-hCG
C. Begin Bromocriptine
D. Obtain a fasting prolactin level
E. Order a ductogram
D. Medical abortion is associated with higher blood loss than surgical
abortion. Early in pregnancy (less than 49 days) both medical and surgical
procedures can be offered. Mifepristone (an antiprogestin) can be
administered, followed by misoprostol (a prostaglandin) to induce uterine
contractions to expel the products of conception. This approach has
proven to be effective (96%) and safe. A surgical termination is required in
the event of failure or excessive blood loss. Medical termination may be
more desirable by some patients since they do not have to undergo a
surgical procedure. It does not affect future fertility. Any termination of
pregnancy, whether medical or surgical, can have psychological sequelae.
B. This patient has puerperal mastitis which most often occurs during the
second to fourth week after delivery and the most appropriate next step in
her management is to use ibuprofen in addition to acetaminophen for pain
relief. She should be encouraged to continue breastfeeding or expressing
their milk during treatment. Mastitis is usually treated as an outpatient.
Patients are treated with oral or IV antibiotics, depending on the severity of
infection. Cold compresses may reduce inflammation but are not indicated
in the management of mastitis. Breast binders may increase breast pain. A
breast ultrasound is not indicated if there is no suspicion of a breast
abscess.
D. Stimulation of the breast during the physical examination may give rise to
an elevated prolactin level. Accurate prolactin levels are best obtained in
the fasting state. If still elevated, then a TSH level and brain MRI would be
indicated to rule out a pituitary tumor. Post partum women may continue to
produce milk for up to two years after cessation of breastfeeding. Although
pathologic factors such as hypothyroidism, hypothalamic disorders,
pituitary disorders (adenomas, empty sella syndrome), chest lesions (breast
implants, thoracotomy scars, and herpes zoster) and renal failure can
elevate prolactin levels, a non-significant benign elevation needs to be
ruled out first. A ductogram is usually indicated in patients who have bloody
discharge from a single breast duct.
26. A 25-year-old G1P1 woman who is breastfeeding her 2 -week-old comes to the office A. Most postpartum mastitis is caused
with left breast pain and fever. The symptoms began earlier today and are not relieved by by staphylococcus aureus, so a
acetaminophen. She has no known drug allergies. Her vital signs are: blood pressure penicillin-type drug is the first line of
120/60; pulse 64; temperature 99.9 F (37.7 C). On exam, there is erythema on the upper treatment. Dicloxacillin is used due to
outer quadrant of the left breast, which is tender to touch; there are no palpable masses. the large prevalence of penicillin
What is the most appropriate antibiotic therapy for this patient? resistant staphylococci. Erythromycin
may be used in penicillin allergic
patients. Doxycycline, gentamicin, and
A. Dicloxacillin cefotetan are not appropriate
B. Erythromycin antibiotics for treatment of mastitis.
C. Doxycycline
D. Gentamicin
E. Cefotetan
27. A 26-year-old G0 presents to the emergency department with eight hours of severe right E. This patient most likely has ovarian
lower quadrant pain associated with nausea. She has a history of suspected torsion and needs to be surgically
endometriosis, which was diagnosed two years ago based on severe dysmenorrhea. She explored. Further imaging studies will
has been using NSAIDs during her menses to control the pain. She is not sexually active. not help beyond the information
She is otherwise in good health. Her menstrual cycles are regular and her last menstrual obtained on the ultrasound. A Doppler
period was three weeks ago. She has no history of sexually transmitted infections. Her ultrasound to check the blood flow to
vital signs are: blood pressure 145/70; pulse 100; temperature 98.6F (37.0C). She appears the ovaries is controversial, as normal
uncomfortable. On abdominal examination, she has moderate tenderness to palpation in flow does not rule out ovarian torsion.
the right lower quadrant. On pelvic examination, she has no lesions or discharge. A Although oral contraceptives can help
thorough bimanual examination was difficult to perform due to her discomfort. Beta-hCG decrease the development of further
<5 mIU/ml and hematocrit 29%. A pelvic ultrasound shows a 6 cm right ovarian mass. The cyst formation and control the pain
uterus and left ovary appear normal. There is a moderate amount of free fluid in the associated with endometriosis, this
pelvis. What is the most appropriate next step in the management of this patient? patient needs immediate surgical
attention due to suspected ovarian
A. Begin oral contraceptives torsion.
B. MRI of the pelvis
C. Doppler pelvic ultrasound
D. CT scan of the pelvis
E. Surgical exploration
28. A 26-year-old G0 woman presents with severe right lower quadrant pain associated with D. The sudden onset of pain and
nausea for the last six hours, which began shortly after she finished her aerobic exercises. nausea, as well as the presence of a
She has a history of suspected endometriosis, which was diagnosed two years ago, based cyst on ultrasound, suggest ovarian
on her severe dysmenorrhea. She has been using NSAIDs during her menses to control torsion. Although appendicitis is in the
the pain. She is not sexually active, and is otherwise in good health. Her menstrual cycles differential diagnosis, it is unlikely to
are regular and her last menstrual period was three weeks ago. She has no history of have such a sudden onset of pain and
sexually transmitted infections. Her vital signs are: blood pressure 145/70; pulse 100; a normal white count. Her
temperature 99.2F (37.3C). She appears uncomfortable. On abdominal examination, she endometriosis can get worse but it
has moderate tenderness to palpation in the right lower quadrant. On pelvic exam, she would be unlikely to be of such
has no lesions or discharge. A thorough bimanual examination is difficult to perform due sudden onset. Although she has an
to her discomfort. Beta-hCG <5 mIU/ml and WBC 8,500 /microliter. A pelvic ultrasound adnexal mass, a negative Beta-hCG
shows a 6 cm right ovarian mass. The uterus and left ovary appear normal. There is a rules out pregnancy.
moderate amount of free fluid in the pelvis. What is the most likely diagnosis in this
patient?

A. Appendicitis
B. Exacerbation of the endometriosis
C. Ovarian carcinoma
D. Ovarian torsion
E. Ectopic pregnancy
29. A 26-year-old G0 woman returns for a
follow-up visit regarding endometriosis.
She has been using NSAIDs to manage her
pelvic pain, but had to miss four days of
work in the last two months. She is sexually
active with her husband of two years,
although it has been more painful recently.
She has regular menstrual cycles and is
using condoms for contraception. On
pelvic examination, she has localized
tenderness in the cul de sac and there are
no palpable masses. What is the most
appropriate next step in the management
of this patient?
C. Oral contraceptives will be the next best choice for this patient. They provide
negative feedback to the pituitary-hypothalamic axis which stops stimulation of the
ovary resulting in ovarian suppression of sex hormone production, such as estrogen.
Since estrogen stimulates endometrial tissue located outside of the endometrium and
uterus, endometriosis can be suppressed by OCPs especially when prescribed in a
continuous fashion (omit the week of placebo pills resulting in no withdrawal bleed).
GnRH agonists also exert negative feedback, but can be used short term only and
have more side effects. Danazol is a synthetic androgen used to treat endometriosis,
but due to its androgenic side effects (weight gain, increased body hair and acne, and
adverse affect on blood lipid levels) it is not usually the first choice of treatment.
Laparoscopy is indicated in the patient who fails medical treatment and/or is planning
pregnancy in the near future. A progesterone intrauterine device might potentially
help alleviate some of her symptoms, but is not the best management for
endometriosis.

A. GnRH agonist
B. Danazol
C. Oral contraceptives
D. Laparoscopy and ablation of
endometriosis
E. Progesterone intrauterine device
30. A 26-year-old G0 women returns for a E. Definitive diagnosis is based on exploratory surgery and biopsies, although
follow-up visit regarding suspected endometriosis is usually initially treated based on the clinical presentation. In addition,
endometriosis. She has been using NSAIDs this patient can benefit from laparoscopy, since she has failed the two most common
and oral contraceptive pills to help treatments for endometriosis, NSAIDs and OCPs. There is no imaging study or blood
manage her pelvic pain which has been test that can confirm the diagnosis of endometriosis. CA-125 is non-specific and can be
getting worse. While discussing further elevated in patients with endometriosis, and therefore not helpful.
treatment options, she asks if there is any
test or procedure you can perform to
confirm her diagnosis. Which of the
following would you recommend?

A. CA-125
B. Pelvic ultrasound
C. CT scan of the abdomen and pelvis
D. MRI of the pelvis
E. Diagnostic laparoscopy
31. A 26-year-old A. The patient is most likely infected with herpes. Herpes simplex virus is a highly contagious DNA virus. Initial
G2P2 woman infection is characterized by viral-like symptoms preceding the appearance of vesicular genital lesions. A
presents with a prodrome of burning or irritation may occur before the lesions appear. With primary infection, dysuria due to
new onset of vulvar lesions can cause significant urinary retention requiring catheter drainage. Pain can be a very significant
vulvar burning finding as well. Treatment is centered on care of the local lesions and the symptoms. Sitz baths, perineal care
and irritation. She and topical Xylocaine jellies or creams may be helpful. Anti-viral medications, such as acyclovir, can decrease
is sexually active viral shedding and shorten the course of the outbreak somewhat. These medications can be administered
with a new male topically or orally. Syphilis is a chronic infection caused by the Treponema pallidum bacterium. Transmission is
partner. She is usually by direct contact with an infectious lesion. Early syphilis includes the primary, secondary, and early latent
using oral stages during the first year after infection, while latent syphilis occurs after that and the patient usually has a
contraception for normal physical exam with positive serology. In primary syphilis, a painless papule usually appears at the site of
birth control and inoculation. This then ulcerates and forms the chancre, which is a classic sign of the disease. Left untreated, 25%
did not use a of patients will develop the systemic symptoms of secondary syphilis, which include low-grade fever, malaise,
condom. She headache, generalized lymphadenopathy, rash, anorexia, weight loss, and myalgias. This patient's symptoms are
thought she had a less consistent with syphilis, but she should still be tested for it. Human immunodeficiency virus is an RNA
cold about 10 retrovirus transmitted via sexual contact or sharing intravenous needles. Vulvar burning, irritation or lesions are
days ago. Which not typically noted with this disease, although generalized malaise can be. HIV can present with many different
of the following is signs and symptoms, therefore risk factors should be considered, and testing offered. Trichomonas is a
the most likely protozoan and is transmitted via sexual contact. It typically presents with a non-specific vaginal discharge. It
diagnosis in this does not have a systemic manifestation.
patient?

A. Herpes simplex
virus
B. Primary syphilis
C. Secondary
syphilis
D. Human
immunodeficiency
virus
E. Trichomonas
32. A 26-year-old G2P2 woman presents with urinary urgency and
dysuria for the past three days. She has a history of a urinary tract
infection once. She is sexually active and uses condoms for
contraception. She is otherwise healthy and does not take any
medications or supplements. She does not have fever, chills, flank
pain or vaginal discharge. Which of the following organisms is the
most likely cause of this patient's symptoms?
E. Acute cystitis in a healthy, non-pregnant woman is
considered uncomplicated and is very common.
Escherichia coli causes 80 to 85 percent of cases. The
other major pathogens are Staphylococcus saprophyticus,
Klebsiella pneumoniae, Enterococcus faecalis and Proteus
mirabilis. The physician must consider antibiotic resistance
when determining treatment.

A. Enterococcus faecalis
B. Klebsiella pneumoniae
C. Proteus mirabilis
D. Staphylococcus saprophyticus
E. Escherichia coli
33. A 26-year-old lesbian has chronic herpetic lesions on her lip. She is A. Use of a dental dam or a latex condom cut down the
concerned about the affect this will have on her partner when she middle is effective in avoiding infection. Type 1 virus can
performs cunnilingus on her. Physical examination is normal except cause ulcers on the vulva, as it is contagious. Prophylaxis of
for a herpetic lesion on the lip, which has been diagnosed as Herpes the partner with acyclovir is not a recommended strategy
type 1 in the past. Acyclovir is prescribed. Which of the following is to prevent transmission, and petrolatum jelly is not an
the most appropriate advice to this patient? effective barrier.
A. Use a dental dam when having oral sex
B. Provide a prescription for acylovir for her partner to take before
and after oral sex
C. Apply a thin layer of petrolatum jelly over her lips while having
oral sex
D. Inform her that the Herpes virus type 1 is not contagious to the
genitalia
E. Discontinue oral sex
34. A 27-year-old G0 woman presents with a one-year history of C. This patient has typical symptoms of endometriosis,
dysmenorrhea and dyspareunia. Pain, when present, is 7/10 in including dysmenorrhea and dyspareunia. In addition, the
strength and requires that she miss work. She now avoids intercourse nodularity along the back of the uterus along the
and no longer finds it pleasurable. She is otherwise in good health. uterosacral ligaments is suggestive of endometriosis.
Her last menstrual period was 17 days ago and her menses are Chronic pelvic inflammatory disease would not present this
typically 28 days apart. She had chlamydia once, at age 19. Physical far out from a known infection. Adenomyosis is endometrial
examination is notable for mild tenderness on abdominal glands embedded in the wall of the uterus. Endometritis is
examination in the lower quadrants, and bilateral adnexal tenderness an infection of the endometrium. Premenstrual dysphoric
on pelvic examination. Uterus is normal in size and there is disorder (PMDD) is a condition in which a woman has
uterosacral ligament nodularity. What is the most likely diagnosis in severe depressive symptoms, irritability, and tension before
this patient? menstruation.

A. Adenomyosis
B. Chronic pelvic inflammatory disease
C. Endometriosis
D. Endometritis
E. Leiomyoma
35. A 27-year-old G0 woman presents with a three-year history of
dyspareunia. She reports a history of always having painful
intercourse, but she is now unable to tolerate intercourse at all.
She has avoided sex for the last six months. She describes
severe pain with penile insertion. On further questioning, she
reports an inability to use tampons because of painful insertion.
She also notes a remote history of frequent yeast infections
while she was on antibiotics for recurrent sinusitis that occurred
years ago. Her medical history is unremarkable, and she is not
on medications. Pelvic examination is remarkable for normal
appearing external genitalia. Palpation of the vestibule with a Q-
tip elicits marked tenderness and slight erythema. A normal-
appearing discharge is noted. Saline wet prep shows only a few
white blood cells, and potassium hydroxide testing is negative.
Vaginal pH is 4.0. The cervix and uterus are unremarkable. Which
of the following is the most likely diagnosis in this patient?
A. Vaginal cancer
B. Genital herpes infection
C. Vestibulodynia
D. Contact dermatitis
E. Chlamydia infection
36. A 28-year-old G0 woman presents for preoperative counseling.
She has a suspected diagnosis of severe endometriosis and has
failed conservative medical management with OCPs. Her
symptoms include severe pelvic pain especially prior to and
during menstruation, and deep dyspareunia. On pelvic
examination, she has uterosacral nodularity and tenderness
throughout both adnexa. Ultrasound reveals normal ovaries
bilaterally. Which of the following procedure is the best option
for this patient?
A. Laser ablation
B. Ovarian cystectomy
C. Salpingectomy
D. Bilateral salpingo-oophorectomy
E. Total laparoscopic hysterectomy and bilateral salpingo-
oophorectomy
37. A 29-year-old G0 woman presents due to the inability to
conceive for the last 18 months. She has a known history of
endometriosis, which was diagnosed by laparoscopy three years
ago. She has pelvic pain, which is controlled with non-steroidal
anti-inflammatory drugs. Her cycles are regular. She is otherwise
in good health and has been married for five years. Her husband
had a semen analysis, which was normal. She had a
hysterosalpingogram, which showed patent tubes bilaterally. She
is getting frustrated that she has not yet achieved pregnancy
and asks to proceed with fertility treatments. What is the most
appropriate next step in the management of this patient?
A. Reassurance and return in six months
B. Administer a GnRH agonist
C. Ovarian stimulation with clomiphene citrate
D. Intrauterine insemination
E. Proceed with in vitro fertilization
C. Vestibulodynia (formally vulvar vestibulitis) syndrome consists
of a constellation of symptoms and findings limited to the vulvar
vestibule, which include severe pain on vestibular touch or
attempted vaginal entry, tenderness to pressure and erythema
of various degrees. Symptoms often have an abrupt onset and
are described as a sharp, burning and rawness sensation.
Women may experience pain with tampon insertion, biking or
wearing tight pants, and avoid intercourse because of marked
introital dyspareunia. Vestibular findings include exquisite
tenderness to light touch of variable intensity with or without
focal or diffuse erythematous macules. Often, a primary or
inciting event cannot be determined. Treatment includes use of
tricyclic antidepressants to block sympathetic afferent pain
loops, pelvic floor rehabilitation, biofeedback, and topical
anesthetics. Surgery with vestibulectomy is reserved for patients
who do not respond to standard therapies and are unable to
tolerate intercourse.
A. Surgery is the gold standard in the diagnosis of
endometriosis, but often is not the initial treatment as suspected
endometriosis is often managed medically. The role of surgery is
often to manage the symptoms of endometriosis, often pelvic
pain. As such, surgery may be conservative (laparoscopic
ablation or excision of implants, excision of endometriomas) or
definitive (total hysterectomy/BSO). In this young nulliparous
patient, definitive surgery is not indicated, and only laser
ablation would be recommended. As she has no evidence of
adnexal masses or enlarged ovaries on ultrasound, it is unlikely
that ovarian cystectomy would be needed. There is no
indication for salpingectomy.
C. A patient with a known history of endometriosis, who is
unable to conceive and has an otherwise negative workup for
infertility, benefits from ovarian stimulation with clomiphene
citrate, with or without intrauterine insemination. Waiting another
six months is not appropriate as she has been trying to conceive
for 18 months unsuccessfully. A GnRH agonist is used to control
pelvic pain in endometriosis patients unresponsive to other
hormonal treatments. In vitro fertilization and adoption can be
offered if other treatments fail.
38. A 29-year-old G0 woman presents due to the inability to conceive for the last year. C. The patient has typical signs of
Her cycles are regular every 28 days, but she has very painful periods, endometriosis which is characterized by the
occasionally requiring that she miss work despite the use of non-steroidal anti- presence of endometrial glands and stroma
inflammatory drugs (NSAIDs). She also reports painful intercourse, which is outside of the uterus. Endometriosis is
becoming a problem as she now tries to avoid intercourse, even though she would present in about 30% of infertile woman. She
like to conceive. She is otherwise in good health and has been married for five does not have the signs and symptoms of
years. She is 5 feet 4 inches tall and weighs 130 pounds. She has a history of pelvic chronic pelvic inflammatory disease. She also
inflammatory disease at age 19, for which she was hospitalized. Her mother had a does not have the signs and symptoms of
history of ovarian cancer at age 49. On physical examination, she has abdominal polycystic ovarian syndrome, which typically
and pelvic lower quadrant tenderness. Uterus is normal in size, but there is a presents with oligomenorrhea in overweight
slightly tender palpable left adnexal mass. A pelvic ultrasound shows a 5 cm left patients. The complex ovarian cyst is most
complex ovarian cyst and two simple cysts measuring 2 cm in the right ovary. What likely an endometrioma (chocolate cyst). The
best explains the underlying pathophysiology of the disease process in this duration of her symptoms makes functional
patient? hemorrhagic cyst a less likely option.

A. Chronic pelvic inflammatory disease

B. Family history of ovarian cancer
C. Endometrial glands outside the uterine cavity
D. Polycystic ovarian syndrome
E. Functional hemorrhagic cysts
39. A 29-year-old G3P0 woman presents for evaluation and treatment of pregnancy C. The prolonged dilute Russell viper venom
loss. Her past medical history is remarkable for three early (< 10 weeks gestation) time, history of three early pregnancy losses,
pregnancy losses and a deep vein thrombosis two years ago. Her work up includes: and a history of venous thrombosis leads one
prolonged dilute Russell viper venom test, elevated anticardiolipin antibodies, to suspect that the etiology of recurrent
normal thyroid function, normal prolactin, and normal MRI of the pelvis. She pregnancy loss is due to antiphospholipid
wishes to get pregnant soon. In addition to aspirin, which of the following antibody syndrome. The treatment is aspirin
treatments is appropriate for this patient? plus heparin. There is roughly a 75% success
rate with combination therapy versus aspirin
A. No additional treatment alone. There is conflicting evidence regarding
B. Corticosteroid steroid use for treatment. 17-OH
C. Heparin progesterone is used for the prevention of
D. 17-OH progesterone preterm delivery and not recurrent
E. Bromocriptine pregnancy loss. Bromocriptine would be
indicated for hyperprolactinemia.
40. A 29-year-old G3P0 woman presents for
evaluation and treatment of pregnancy loss. Her
past medical history is remarkable for three early
(<14 weeks gestation) pregnancy losses. Parental
karyotype was normal. Which of the following is
the most appropriate next step in the
management of this patient?
A. Prophylactic cerclage with her next pregnancy
B. Serial cervical length with her next pregnancy
C. 17-hydroxyprogesterone with her next
pregnancy
D. Check for Factor V Leiden mutation
E. Check antiphospholipid antibodies
41. A 30-year-old G1P1 woman presents with a
history of chronic vulvar pruritus. The itching is
so severe that she scratches constantly and is
unable to sleep at night. She reports no
significant vaginal discharge or dyspareunia. She
does not take antibiotics. Her medical history is
unremarkable. Pelvic examination reveals normal
external genitalia with marked lichenification
(increased skin markings) and diffuse vulvar
edema and erythema as shown in picture below.
Saline microscopy is negative. Potassium
hydroxide testing is negative. Vaginal pH is 4.0.
The vaginal mucosa is normal. Which of the
following is the most likely diagnosis in this
patient?
A. Lichen simplex chronicus
B. Lichen sclerosus
C. Lichen planus
D. Candidiasis
E. Vulvar cancer
42. A 32-year-old G0 woman comes to your office
because she has been unable to conceive for
one year. She is currently in a mutually
monogamous relationship with her husband, has
intercourse three times per week, and has no
dyspareunia. Her menstrual cycles occur every
26-34 days. She has had seven sexual partners in
the past. She was treated for multiple sexually
transmitted infections including gonorrhea,
chlamydia and pelvic inflammatory disease in
her early twenties. She had an abnormal Pap test
about four years ago and was treated with a
LEEP. What is the most likely underlying cause of
infertility in this patient?
A. Luteal phase defect
B. Cervical stenosis
C. Ovulatory dysfunction
D. Tubal disease
E. Endometriosis
E. Antiphosphospholipid antibodies are associated with recurrent pregnancy
loss. The workup for antiphospholipid syndrome includes assessment of
anticardiolipin and beta-2 glycoprotein antibody status, PTT, and Russell viper
venom time. Recurrent pregnancy loss is defined as > two consecutive or > three
spontaneous losses before 20 weeks gestation. Etiologies include anatomic
causes, endocrine abnormalities such as hyper- or hypothyroidism and luteal
phase deficiency, parental chromosomal anomalies, immune factors such as
lupus anticoagulant and idiopathic factors. Her history is not consistent with
cervical insufficiency which is diagnosed in the second trimester by history,
physical exam and other diagnostic tests, such as ultrasound. Serial cervical
lengths or placement of a cerclage are not indicated in this patient. Treatment
with 17-hydroxyprogesterone is indicated in patients with a history of prior
preterm birth. Factor V Leiden mutation has not been associated with recurrent
pregnancy loss. It can be associated with thrombotic events.
A. Lichen simplex chronicus, a common vulvar non-neoplastic disorder, results
from chronic scratching and rubbing, which damages the skin and leads to loss
of its protective barrier. Over time, a perpetual itch-scratch-itch cycle develops,
and the result is susceptibility to infection, ease of irritation and more itching.
Symptoms consist of severe vulvar pruritus, which can be worse at night. Clinical
findings include thick, lichenified, enlarged and rugose labia, with or without
edema. The skin changes can be localized or generalized. Diagnosis is based on
clinical history and findings, as well as vulvar biopsy. Treatment involves a short-
course of high-potency topical corticosteroids and antihistamines to control
pruritus.
D. The rate of tubal infertility has been reported as 12% after one episode of PID,
25% after 2 episodes and 50% after three episodes. Salpingitis can develop in
15-30% of women with inadequately treated gonococcal or chlamydial
infections and can result in significant long-term sequelae, such as chronic
pelvic pain, hydrosalpinx, tubal scarring and ectopic pregnancy. Given this
patient's history, her inability to conceive is most likely due to the long-term
sequelae of a sexually transmitted infection. Although the patient had a LEEP,
risk for cervical stenosis is low. She is having regular cycles; therefore,
anovulation and luteal phase defect is less likely. This case emphasizes the
importance of aggressive screening and treatment protocols for sexually
transmitted infections, as well as counseling regarding abstinence and safer sex
practices. While endometriosis can cause tubal occlusion, her clinical
presentation is not consistent with endometriosis.
43. A 32-year-old G0 woman presents with a one-month
history of profuse vaginal discharge with mild odor. She
has a new sexual partner with whom she has had
unprotected intercourse. She reports mild to moderate
irritation, pruritus and pain. She thought she had a yeast
infection, but had no improvement after using an over-
the-counter antifungal cream. She is concerned about
sexually transmitted infections. Her medical history is
significant for lupus and chronic steroid use. Pelvic
examination shows normal external genitalia, an
erythematous vagina with a copious, frothy yellow
discharge and multiple petechiae on the cervix. Vaginal
pH is 7. Which of the following findings on a wet prep
explains the etiology of this condition?
A. Hyphae
B. Clue cells
C. Trichomonads
D. Lactobacilli
E. Normal epithelial cells
44. A 32-year-old G0 woman with a last menstrual period
three weeks ago, presents with a three-month history of a
malodorous vaginal discharge. She reports no pruritus or
irritation. She has been sexually active with a new partner
for the last four months. Her past medical history is
unremarkable. Pelvic examination reveals normal external
genitalia without rash, ulcerations or lesions. Some
discharge is noted on the perineum. The vagina reveals
only a thin, gray homogeneous discharge. The vaginal pH
is 5.0. A wet prep is shown in the image below. Which of
the following is the most appropriate treatment for this
patient?
A. Ceftriaxone
B. Doxycycline
C. Metronidazole
D. Azithromycin
E. Penicillin
45. A 32-year-old G3P1 woman presents to your office today
because of exposure to hepatitis B. She had vaginal and
anal intercourse with a new partner three days ago and
did not use condoms. The partner informed her today he
was recently diagnosed with acute hepatitis B acquired
from intravenous drug use and needle sharing. She has no
prior history of hepatitis B infection and has not been
vaccinated. She is currently asymptomatic and her
examination is normal. Her urine pregnancy test is
negative. What is the next best step in the management of
this patient?
A. Check AST, ALT, and HBsAg
B. Administer HBIG one dose
C. Administer HBIG two doses
D. Administer HBIG and start hepatitis B vaccine series
E. Administer hepatitis B vaccine series only
C. This patient has signs and symptoms of trichomoniasis, which is
caused by the protozoan, T. vaginalis. Many infected women have
symptoms characterized by a diffuse, malodorous, yellow-green
discharge with vulvar irritation. However, some women have minimal or
no symptoms. Diagnosis of vaginal trichomoniasis is performed by
saline microscopy of vaginal secretions, but this method has a
sensitivity of only 60% to 70%. The CDC recommended treatment is
metronidazole 2 grams orally in a single dose. An alternate regimen is
metronidazole 500mg orally twice daily for seven days. The patient's
sexual partner also should undergo treatment prior to resuming sexual
relations.
C. Bacterial vaginosis is the most common cause of vaginitis. The
infection arises from a shift in the vaginal flora from hydrogen
peroxide-producing lactobacilli to non-hydrogen peroxide-producing
lactobacilli, which allows proliferation of anaerobic bacteria. The
majority of women are asymptomatic; however, patients may
experience a thin, gray discharge with a characteristic fishy odor that is
often worse following menses and intercourse. Modified Amsel criteria
for diagnosis include three out of four of the following: 1) thin, gray
homogenous vaginal discharge; 2) positive whiff test (addition of
potassium hydroxide releases characteristic amine odor); 3) presence
of clue cells on saline microscopy; and 4) elevated vaginal pH >4.5.
Treatment consists of Metronidazole 500 mg orally BID for seven days,
or vaginal Metronidazole 0.75% gel QHS for five days.
D. It is estimated that 38% of hepatitis B cases worldwide are acquired
from sexual transmission. Post-exposure prophlaxis should be inititated
as soon as possible but not later than 7 days after blood contact and
within 14 days after sexual exposure. In individuals who are
unvaccinated but exposed to persons who are HBsAG positive,
recommendations are to receive one dose of HBIG (Hepatitis B
Immune Globulin) and the HBV (Hepatitis B Vaccine Series). If the
source is HBsAG negative or unknown status, then only the HBV series
is used. If the exposed individual has been vaccinated and is a
responder then no further treatment is necessary. If the exposed
individual is vaccinated and a non-responder, then HBIG plus HBV or
HBIG times two doses is used. Because the incubation period for the
virus is six weeks to six months, checking liver function and
immunologic status at this time is not indicated.`
46. A 32-year-old G3P2 woman with a last menstrual
period two weeks ago presents with a six-month
history of abdominal pain. She has noncyclic
intermittent pain, which she describes as crampy
and diffuse across the lower abdomen. Her pain
is typically relieved with defecation and is
associated with loose, watery stools. Onset of the
symptoms is associated with a change in stool
frequency from once daily to multiple times
daily. She also experiences bloating and
abdominal distention several times a week. Her
medical history is significant for chronic
migraines and she denies previous surgery. Her
gynecological history is unremarkable. Her
abdominal examination is notable for mild
tenderness to palpation in the left lower
quadrant, and her pelvic examination is normal.
What is the most likely diagnosis in this patient?
A. Pelvic adhesions
B. Diverticulosis
C. Endometriosis
D. Irritable bowel syndrome
E. C. difficile colitis
47. A 32-year-old G3P3 woman comes to the office
to discuss permanent sterilization. She has a
history of hypertension and asthma (on
corticosteroids). She has been married for 10
years. Vital signs show: blood pressure 140/90;
weight 280 pounds; height 5 feet 9 inches; and
BMI 41.4kg/m2. You discuss with her risks and
benefits of contraception. Which of the following
would be the best form of permanent sterilization
to recommend for this patient?
A. Laparoscopic bilateral tubal ligation
B. Mini laparotomy tubal ligation
C. Exploratory laparotomy with bilateral
salpingectomy
D. Total abdominal hysterectomy
E. Vasectomy for her husband
D. Irritable bowel syndrome (IBS) is a common functional bowel disorder of
uncertain etiology. It is characterized by a chronic, relapsing pattern of
abdominal and pelvic pain, and bowel dysfunction with constipation or
diarrhea. IBS is one of the most common disorders associated with chronic
pelvic pain. IBS appears to occur more commonly in women with chronic pelvic
pain than in the general population. Diagnosis is based on the Rome II Criteria
for IBS, which includes at least 12 weeks (need not be consecutive) in the
preceding 12 months of abdominal discomfort or pain that has two of three
features: 1) relief with defecation; 2) onset associated with a change in frequency
of stool; or 3) onset associated with a change in stool form or appearance. The
patient's history does not support pelvic adhesions, and diverticulosis (although
very common) typically may be asymptomatic unless inflammation/infection
develops. In this case, the symptoms for IBS may be indistinguishable from
diverticulitis or severe diverticular disease. Although severe endometriosis may
affect the lower bowel with constricting and invasive implants, the lack of any
gynecologic/menstrual symptoms and the normal pelvic examination essentially
excludes this diagnosis. The lack of recent antibiotic exposure essentially rules
out the diagnosis of C. difficile.
E. Both vasectomy and tubal ligation are 99.8% effective. Vasectomies are
performed as an outpatient procedure under local anesthesia, while tubal
ligations are typically performed in the operating room under regional or
general anesthesia; therefore carrying slightly more risk to the woman, assuming
both are healthy. She is morbidly obese, so the risk of anesthesia and surgery
are increased. In addition, she has chronic medical problems that put her at
increased risk of having complications from surgery.
48. A 33-year-old G2P2 woman reports a two-
year history of severe dysmenorrhea,
menorrhagia and pelvic pain following the
delivery of her last child. She describes her
pelvic pain as primarily in the right lower
quadrant, radiating into the vagina. Her
pain worsens throughout the day with
standing and is associated with pelvic
pressure and fullness. Her pelvic
examination reveals a mildly enlarged
uterus with marked tenderness to palpation
of the right adnexa, and no other
significant findings. A vaginal ultrasound
with color-flow Doppler reveals multiple
dilated vessels traversing the right broad
ligament to the lower uterus and cervix.
The uterus shows no fibroids or other
significant changes. Endometrial thickness
appears normal. Which of the following is
the most likely diagnosis in this patient?
A. Endometriosis
B. Endometritis
C. Adenomyosis
D. Pelvic congestion
E. Pelvic floor relaxation
49. A 33-year-old G3P3 woman presents to the
office complaining of a new onset vaginal
discharge of four days duration. The
discharge is thick and white. She has noted
painful intercourse and itching since the
discharge began. Her vital signs are: blood
pressure 120/76 and pulse 78. The pelvic
examination reveals excoriations on the
perineum, thick white discharge, and is
otherwise non-contributory. What is the
most likely diagnosis in this patient?
A. Herpes simplex virus
B. Primary syphilis
C. Candida vaginalis
D. Bacterial vaginosis
E. Trichomonas
D. Pelvic congestion syndrome is a cause of chronic pelvic pain occurring in the
setting of pelvic varicosities. The unique characteristics of the pelvic veins make them
vulnerable to chronic dilatation with stasis leading to vascular congestion. These veins
are thin walled and unsupported, with relatively weak attachments between the
supporting connective tissue. The cause of pelvic vein congestion is unknown.
Hormonal factors contribute to vasodilatation when pelvic veins are exposed to high
concentration of estradiol, which inhibits reflex vasoconstriction of vessels, induces
uterine enlargement with selective dilatation of ovarian and uterine veins. This pain
may be of variable intensity and duration, is worse premenstrually and during
pregnancy, and is aggravated by standing, fatigue and coitus. The pain is often
described as a pelvic "fullness" or "heaviness," which may extend to the vulvar area
and legs. Associated symptoms include vaginal discharge, backache and urinary
frequency. Menstrual cycle defects and dysmenorrhea are common. No signs of
pelvic floor relaxation were noted on exam.
C. The patient is most likely has candida vaginalis. Clinically women have itching and
thick white cottage cheese like discharge. They may also have burning with urination
and pain during intercourse. Herpes simplex viral infections are characterized by viral
like symptoms preceding the appearance of vesicular genital lesions. A prodrome of
burning or irritation may occur before the lesions appear. With primary infection,
dysuria due to vulvar lesions can cause significant urinary retention requiring catheter
drainage. Pain can be a very significant finding as well. Syphilis is a chronic infection
caused by the Treponema pallidum bacterium. Transmission is usually by direct
contact with an infectious lesion. Early syphilis includes the primary, secondary, and
early latent stages during the first year after infection, while latent syphilis occurs after
that and the patient usually has a normal physical exam with positive serology. In
primary syphilis, a painless papule usually appears at the site of inoculation. This then
ulcerates and forms the chancre, which is a classic sign of the disease. Left untreated,
25% of patients will develop the systemic symptoms of secondary syphilis, which
include low-grade fever, malaise, headache, generalized lymphadenopathy, rash,
anorexia, weight loss, and myalgias. Bacterial vaginosis is due to an overgrowth of
anaerobic bacteria and characterized by a grayish / opaque foul-smelling discharge.
Trichomonas is a protozoan and is transmitted via sexual contact. It typically presents
with a non-specific yellow or greenish vaginal discharge. It does not have a systemic
manifestation.
50. A 35-year-old G1P0 woman with last menstrual period one week
ago presents with an eight-month history of pelvic pain. She
reports regular menstrual cycles with moderate flow and
dysmenorrhea, relieved with ibuprofen. She describes her pain
as a deep, achy sensation with frequent sharp exacerbations.
She has not been sexually active for the last several months
because of dyspareunia and some arguments with her new
partner of one year. She has no history of sexually transmitted
infections. Her medical history is significant for irritable bowel
syndrome, managed with a fiber supplement. She is a business
executive. She has smoked one pack of cigarettes a day since
age 25, and drinks a glass of wine three times a week. She tries
to exercise regularly by running three to four times a week. This
new pain is distinctly different from her IBS symptoms. Which of
the following risk factors can contribute to increased incidence
of pelvic pain in this patient?
A. Alcohol use
B. Smoking habit
C. Occupation
D. New partner
E. Age
51. A 35-year-old G3P3 woman comes to the office because she
desires contraception. Her past medical history is significant for
Wilson's disease, chronic hypertension and anemia secondary to
menorrhagia. She is currently on no medications. Her vital signs
reveal a blood pressure of 144/96. Which of the following
contraceptives is the best option for this patient?
A. Progestin-only pill
B. Low dose combination contraceptive
C. Continuous oral contraceptive
D. Copper containing intrauterine device
E. Levonorgestrel intrauterine device
52. A 35-year-old G3P3 woman requests contraception. Her
youngest child is seven years old. Her periods have been regular
since she discontinued breastfeeding five years ago. Her past
medical history includes depression that is controlled with
antidepressants, and a history of deep venous thrombosis. She
denies smoking or alcohol use. In the past, oral contraceptive
pills have caused her to have severe gastrointestinal upset. What
in her history makes her an ideal candidate for progestin-only
pills?
A. Depression
B. Smoking history
C. Severe nausea on combined oral contraceptives
D. Lactation history
E. Deep venous thrombosis
D. Most published evidence suggests a significant association of
physical and sexual abuse with various chronic pain disorders.
The arguments with the new partner allude to possible abuse.
Studies have found that 40-50% of women with chronic pelvic
pain have a history of abuse. Whether abuse (physical or sexual)
specifically causes chronic pelvic pain is not clear, nor is a
mechanism established by which abuse might lead to the
development of chronic pelvic pain. Women with a history of
sexual abuse and high somatization scores have been found to
be more likely to have non-somatic pelvic pain, suggesting the
link between abuse and chronic pelvic pain may be psychologic
or neurologic. However, studies also suggest that trauma or
abuse may also result in biophysical changes, by literally
heightening a person's physical sensitivity to pain. While smoking
can be associated with dysmenorrhea, she has been smoking for
10 years and her symptoms are recent onset.
E. The levonorgestrel intrauterine device has lower failure rates
within the first year of use than does the copper containing
intrauterine device. It causes more disruption in menstrual
bleeding, especially during the first few months of use, although
the overall volume of bleeding is decreased long-term and
many women become amenorrheic. The levonorgestrel
intrauterine device is protective against endometrial cancer due
to release of progestin in the endometrial cavity. She is not a
candidate for oral contraceptive pills because of her poorly
controlled chronic hypertension. The progestin-only pills have a
much higher failure rate than the progesterone intrauterine
device. She is not a candidate for the copper-containing
intrauterine device because of her history of Wilson's disease.
E. Ideal candidates for progestin-only pills include women who
have contraindications to using combined oral contraceptives
(estrogen and progestin containing). Contraindications to
estrogen include a history of thromboembolic disease, women
who are lactating, women over age 35 who smoke or women
who develop severe nausea with combined oral contraceptive
pills. Progestins should be used with caution in women with a
history of depression.
53. A 36-year-old G0 woman presents to the emergency
department accompanied by her female partner. The patient
notes severe abdominal pain. She states that this pain began 2-
3 days ago and was associated with diarrhea as well as some
nausea. It has gotten progressively worse and she has now
developed a fever. Neither her partner, nor other close
contacts, report any type of viral illness. She had her appendix
removed as a teenager. On examination, her temperature is
102.0F (38.9C), her abdomen is tender with mild guarding and
rebound, and she has an elevated white count. On pelvic
examination, she is exquisitely tender, such that you cannot
complete the examination. Pelvic ultrasound demonstrates
bilateral 3-4 cm complex masses. What is the most likely
underlying pathogenesis of her illness?
D. Although salpingitis is most often caused by sexually
transmitted agents such as gonorrhea and chlamydia, any
ascending infection from the genitourinary tract or gastrointestinal
tract can be causative. The infection is polymicrobial consisting of
aerobic and anaerobic organisms such as E. coli, Klebsiella, G.
vaginalis, Prevotella, Group B streptococcus and/or enterococcus.
Although diverticulitis and gastroenteritis should be part of the
differential diagnosis initially, the specific findings on examination
and ultrasound are more suggestive of bilateral tubo-ovarian
abscesses. Even though this patient does not have the typical risk
factors for salpingitis, the diagnosis should be considered and
explained to the patient in a sensitive and respectful manner. The
patient should also be questioned separate from her partner
regarding the possibility of other sexual contacts.

A. Diverticulitis
B. Gastroenteritis
C. Reactivation of an old infection
D. Ascending infection
E. Pyelonephritis
54. A 36-year-old G2P0 woman at 11 weeks gestational age
requests a surgical termination of pregnancy. She had a
manual vacuum aspiration last year and would like to undergo
the same procedure again. She has chronic hypertension and
diabetes well controlled on medications. Vital signs reveal a
blood pressure of 120/80 and fasting blood glucose of 100.
Which of the following is a contraindication for manual vacuum
aspiration of this patient?
C. Manual vacuum aspiration is more than 99% effective in early
pregnancy (less than eight weeks). Age, parity and medical
illnesses are not contraindications for manual vacuum aspiration.
Although the risk of Asherman's syndrome increases with each
subsequent pregnancy termination, this patient may still undergo
surgical termination as long as she understands risks and benefits.
Complications of pregnancy termination increase with increasing
gestational age.

A. Age
B. Parity
C. Gestational age
D. Chronic hypertension
E. Diabetes
55. A 36-year-old G2P2 woman presents with irregular vaginal A. The patient should be reassured since initially after Depo-
bleeding. Six weeks ago, she had her first Depo-Provera Provera injection there may be unpredictable bleeding. This
injection and now she has unpredictable bleeding. She is usually resolves in 2-3 months. In general, after one year of using
concerned by these symptoms. She has a history of Depo-Provera, nearly 50% of users have amenorrhea.
hypertension but is currently on no medications. Vital signs
reveal: blood pressure 130/90; weight 188 pounds; height 5
feet 5 inches; BMI 31.4kg/m2. Which of the following is the
most appropriate next step in the management of this patient?

A. Reassurance
B. Begin oral contraceptives
C. Begin estrogen
D. Insert etonogestrel implant (Implanon)
E. Perform an endometrial biopsy
56. A 37-year-old G0 woman presents
with a one-week history of a mildly
painful vulvar ulcer. She reports no
fevers, malaise or other systemic
symptoms. She recently started
use of a topical steroid ointment
for a vulvar contact dermatitis. She
is married and has no prior history
of sexually transmitted infections.
She reports no travel outside the
United States by her husband or
herself. Her last Pap smear, six
months ago, was normal. A vulvar
herpes culture later returns
positive for herpes simplex virus
type 2. A Rapid Plasma Reagin
(RPR) is nonreactive, and HIV
testing is negative. Which of the
following is the most likely
diagnosis in this patient?
A. Primary HSV episode
B. Recurrent HSV-1 episode
C. Recurrent HSV-2 episode
D. Atypical HSV episode
E. Contact dermatitis
57. A 37-year-old G3P3 woman
presents for contraceptive
counseling. She and her husband
have decided that they no longer
plan to have children and desire
permanent sterilization. Her
husband refuses to have a
vasectomy. On exam, her BMI is 52;
blood pressure is 140/80; and
heart rate is 86. She has had three
previous Cesarean deliveries.
Which of the following options
would be the be the best method
of permanent sterilization?
A. Laparoscopic tubal ligation
B. Mini-laparotomy with tubal
ligation
C. Hysterectomy
D. Hysteroscopic tubal occlusion
(Essure)
E. Endometrial ablation
C. Two serotypes of HSV have been identified: HSV-1 and HSV-2. Most cases of recurrent
genital herpes are caused by HSV-2. Up to 30% of first-episode cases of genital herpes are
caused by HSV-1, but recurrences are much less frequent for genital HSV-1 infection than
genital HSV-2 infection. Genital HSV infections are classified as initial primary, initial nonprimary,
recurrent and asymptomatic. Initial, or first-episode primary genital herpes is a true primary
infection (i.e. no history of previous genital herpetic lesions, and seronegative for HSV
antibodies). Systemic symptoms of a primary infection include fever, headache, malaise and
myalgias, and usually precede the onset of genital lesions. Vulvar lesions begin as tender
grouped vesicles that progress into exquisitely tender, superficial, small ulcerations on an
erythematous base. Initial, nonprimary genital herpes is the first recognized episode of genital
herpes in individuals who are seropositive for HSV antibodies. Prior HSV-1 infection confers
partial immunity to HSV-2 infection and thereby lessens the severity of type 2 infection. The
severity and duration of symptoms are intermediate between primary and recurrent disease,
with individuals experiencing less pain, fewer lesions, more rapid resolution of clinical lesions
and shorter duration of viral shedding. Systemic symptoms are rare. Recurrent episodes involve
reactivation of latent genital infection, most commonly with HSV-2, and are marked by episodic
prodromal symptoms and outbreaks of lesions at varying intervals and of variable severity.
Clinical diagnosis of genital herpes should be confirmed by viral culture, antigen detection or
serologic tests. Treatment consists of antiviral therapy with acyclovir, famciclovir or valacyclovir.
D. Hysteroscopic tubal occlusion is the best option for this patient. Hysteroscopic tubal
occlusion (Essure) can be performed in the office and places coils into the fallopian tubes that
cause scarring that blocks the tubes. Patients are required to use a back up method of
contraception for three months following the procedure until a hysterosalpingogram is
performed confirming complete occlusion of the tubes. While tubal ligation, either by
laparoscopy or mini-laparotomy, are common and effective forms of permanent sterilization,
for this patient with her BMI and previous surgeries, this would carry more surgical risks.
Hysterectomy is not an indicated procedure for sterilization. Endometrial ablation, or thermal
destruction of the endometrial tissue, is an effective treatment for menorrhagia but is not
reliable for permanent sterilization.
58. A 38-year-old G0 woman comes to the office for a health
maintenance examination. She is healthy and not taking
any medications. She has no history of abnormal Pap
tests or sexually transmitted infections. Her menstrual
cycles are normal and her last cycle was three weeks
ago. Her mother was diagnosed with endometriosis and
had a hysterectomy and removal of the ovaries at age 38.
She is 5 feet 4 inches tall and weighs 130 pounds. On
pelvic examination, the patient has a palpable left
adnexal mass. An ultrasound was obtained, which showed
a 4 cm complex left ovarian cyst and a 2 cm simple cyst
on the right ovary. What is the most likely diagnosis in this
patient?
A. Endometrioma
B. Hemorrhagic cyst
C. Ovarian carcinoma
D. Mature teratoma
E. Polycystic ovaries
59. A 42-year-old G2P2 woman presents with a two-week
history of a thick, curdish white vaginal discharge and
pruritus. She has not tried any over-the-counter
medications. She is currently single and not sexually
active. Her medical history is remarkable for recent
antibiotic use for bronchitis. On pelvic examination, the
external genitalia show marked erythema with satellite
lesions. The vagina appears erythematous and
edematous with a thick white discharge. The cervix
appears normal and the remainder of the exam is
unremarkable except for mild vaginal wall tenderness.
Vaginal pH is 4.0. Saline wet prep reveals multiple white
blood cells, but no clue cells or trichomonads. Potassium
hydroxide prep shows the organisms. Which of the
following is the most appropriate treatment for this
patient?
A. Clindamycin
B. Azole cream
C. Metronidazole
D. Doxycycline
E. Ciprofloxacin
B. This patient most likely has a hemorrhagic cyst, considering her
history and where she is in her menstrual cycle. Her mother's history of
endometriosis does increase her risk; however, it is unlikely since she
has never had any symptoms herself. Ovarian carcinoma would need to
be ruled out, but it is unlikely in an otherwise asymptomatic
premenopausal patient. A mature teratoma would have more
pathognomonic findings on ultrasound. This patient does not have
typical symptoms, body habitus or ultrasound findings for patients with
polycystic ovaries.
B. Vulvovaginal candidiasis (VVC) usually is caused by C. albicans, but is
occasionally caused by other Candida species or yeasts. Typical
symptoms include pruritus and vaginal discharge. Other symptoms
include vaginal soreness, vulvar burning, dyspareunia and external
dysuria. None of these symptoms are specific for VVC. The diagnosis is
suggested clinically by vulvovaginal pruritus and erythema with or
without associated vaginal discharge. The diagnosis can be made in a
woman who has signs and symptoms of vaginitis when either: a) a wet
preparation (saline or 10% KOH) or Gram stain of vaginal discharge
demonstrates yeasts or pseudohyphae; or b) a vaginal culture or other
test yields a positive result for a yeast species. Microscopy may be
negative in up to fifty percent of confirmed cases. Treatment for
uncomplicated VVC consists of short-course topical Azole formulations
(1-3 days), which results in relief of symptoms and negative cultures in
80%-90% of patients who complete therapy.
60. A 42-year-old G2P2 woman presents with chronic pelvic pain of
two years duration. She describes the pain as constant ever since
she underwent a laparoscopic-assisted vaginal hysterectomy for
menorrhagia and dysmenorrhea. She did not have any evidence of
endometriosis or obvious ovarian pathology at the time of surgery.
During the postoperative period, she developed pelvic pain and
fever, and was diagnosed with a pelvic/vaginal cuff abscess that
was treated with antibiotics and percutaneous drainage. Her pain
persisted in the subsequent months. Follow-up imaging over the
next two years indicated transient ovarian cysts. Her abdominal
examination is notable for mild-moderate tenderness across the
lower quadrants, and her pelvic examination is notable for severe
tenderness at the vaginal cuff with fullness noted in the midline.
Which of the following is the most likely diagnosis in this patient?
A. Endometriosis
B. Pelvic inflammatory disease
C. Pelvic adhesive disease
D. Ovarian remnant syndrome
E. Ovarian cancer
61. A 42-year-old G3P3 woman comes to the office after noticing a
breast mass while performing a breast self-exam. She is in good
health and has normal menstrual cycles. Family history is
significant for multiple first and second-degree relatives having
breast cancer. Physical exam reveals a 2 cm dominant breast mass.
The remainder of the exam is normal. A mammogram obtained
today shows no abnormalities. What is the most appropriate next
step in the management of this patient?
A. Reassurance and observation
B. Obtain genetic testing for BRCA1 and BRCA2
C. MRI of the breast
D. Fine needle aspiration
E. Repeat mammogram in two months
62. A 42-year-old G3P3 woman comes to the office after noticing a
breast mass while performing a breast self-exam. She is in good
health and has normal menstrual cycles. Physical exam is
significant for a 2 cm dominant breast mass. The remainder of the
exam is normal. A mammogram obtained today shows no
abnormalities. A fine needle aspiration was negative, and the mass
persisted. What is the most appropriate next step in the
management of this patient?
A. Reassurance and observation
B. Obtain an MRI of the chest
C. Breast ultrasound
D. Perform an excisional biopsy
E. Repeat mammogram in two months
C. The patient most likely has pelvic adhesive disease as a
result of her prior hysterectomy. The development of a
postoperative pelvic infection likely has contributed to the
further development of pelvic adhesions involving the tubes
and ovaries that were retained. Although she did have a pelvic
infection, it is unlikely that her pain resulted from classic PID
since her adnexa appeared normal at the time of the
hysterectomy. It is likely that her tubes and ovaries were
affected by the postoperative infection, and as a result she
may develop chronic pain from the adhesive disease and tubal
damage from that acute infection. The cyclical nature of the
ovarian cyst essentially rules out ovarian cancer. Ovarian
remnant syndrome occurs following surgical removal of the
ovaries, with subsequent development of cyclical pain due to
ovarian tissue that was left behind inadvertently.
D. Given her positive family hx, can assume that the
mammogram might be a false negative. she is >25yo, so go for
the FNA.
D. A specimen obtained on fine-needle aspiration (FNA) is
examined both histologically and cytologically. An excisional
biopsy should be performed when the results are negative,
due to the possibility of a false-negative result. FNA can,
however, prevent the need for other diagnostic testing and is
the appropriate first step in the evaluation of a palpable
breast mass. Breast ultrasound can be used to distinguish
between a cyst and a solid mass. Fine needle aspiration under
ultrasound guidance can help distinguish a fibroadenoma from
a cyst and exclude cancer in certain situations. A normal
mammogram does not rule out breast cancer and there is no
need to repeat it in two months. There are no indications for
obtaining an MRI of the chest in the initial diagnosis of this
patient.
63. A 45-year-old G2P2 woman underwent
an abdominal hysterectomy for a large
fibroid uterus via a low transverse skin
incision. Her postoperative course was
significant for new onset right lower
quadrant pain and numbness, radiating
into the right inguinal area and medial
thigh. Her pain was exacerbated by
adduction of her right thigh. On
abdominal examination, there is a well-
healed low transverse incision. Her pain is
reproduced with adduction of the right
thigh. There is decreased sensation to
light touch and pinprick over the right
inguinal area and right medial thigh.
Patellar reflexes are 2+ and symmetric.
Entrapment of which of the following
nerves is the most likely cause of her
pain?
A. Obturator nerve
B. Ilioinguinal nerve
C. Lateral femoral cutaneous nerve
D. Femoral nerve
E. Iliohypogastric nerve
64. A 46-year-old female is scheduled to
undergo a total laparoscopic
hysterectomy for menorrhagia. She
comes into your office to discuss the
effects a hysterectomy will have on her
sex life. She is concerned about how a
hysterectomy will affect her
"womanhood" and read in a woman's
magazine that the cervix, as well as the
uterus, is necessary for orgasm. Which of
the following organs is most responsible
for sexual arousal?
A. Vulva
B. Cervix
C. Uterus
D. Ovary
E. All of the above
B. Nerve entrapment syndrome is a commonly misdiagnosed neuropathy that can
complicate pelvic surgical procedures performed through a low transverse incision. The
nerves at risk are the iliohypogastric nerve (T-12, L-1) and the ilioinguinal (T-12, L-1) nerve.
These two nerves exit the spinal column at the 12th vertebral body and pass laterally
through the psoas muscle before piercing the transversus abdominus muscle to the
anterior abdominal wall. Once at the anterior superior iliac spine, the iliohypogastric
nerve courses medially between the internal and external oblique muscles, becoming
cutaneous 1 cm superior to the superficial inguinal ring. The iliohypogastric nerve
provides cutaneous sensation to the groin and the skin overlying the pubis. The
ilioinguinal nerve follows a similar, although slightly lower, course as the iliohypogastric
nerve where it provides cutaneous sensation to the groin, symphysis, labium and upper
inner thigh. These nerves may become susceptible to injury when a low transverse
incision is extended beyond the lateral border of the rectus abdominus muscle, into the
internal oblique muscle. Symptoms are attributed to suture incorporation of the nerve
during fascial closure, direct nerve trauma with subsequent neuroma formation, or
neural constriction due to normal scarring and healing. Damage to the obturator nerve,
which can occur during lymph node dissection would result in the inability of the patient
to adduct the thigh.
A. The external genitalia, specifically the clitoris, are essential organs involved in the
arousal component of the sexual response cycle, which consists of desire, arousal,
orgasm, and resolution. Hormones such as androgen and estrogen (produced by the
ovaries) are key to desire, while genital mechanisms such as clitoral, labial, and vaginal
engorgement are key to arousal. With arousal and adequate sensory stimulation,
orgasm ultimately may occur consisting of repeated motor contractions of the pelvic
floor including uterine and vaginal smooth muscle contractions.
65. A 48-year-old G0 comes to the office for a health maintenance B. A repeat ultrasound is the most appropriate next step, as this
examination. She is healthy and not taking any medications. She is most likely a hemorrhagic cyst which will resolve on its own.
has no history of abnormal Pap tests or sexually transmitted Oral contraceptives are contraindicated in this patient, as she is
infections. She is not currently sexually active. Her menstrual older than 35 and smokes. A CT scan of the pelvis will not add
cycles are normal and her last cycle was three weeks ago. She any more information. Needle aspiration is not the standard of
smokes one pack of cigarettes per day. Her mother was care in this asymptomatic premenopausal patient. There is no
diagnosed with endometriosis and had a hysterectomy and indication to proceed with a TAH/BSO.
removal of the ovaries at age 38. She is 5 feet 4 inches tall and
weighs 130 pounds. On pelvic examination, the patient has a
palpable left adnexal mass. An ultrasound was obtained, which
showed a 4 cm complex left ovarian cyst and a 2 cm simple cyst
on the right ovary. What is the most appropriate next step in the
management of this patient?

A. Oral contraceptives
B. Repeat ultrasound in two months
C. CT scan of the abdomen and pelvis
D. Needle aspiration of the cyst
E. Abdominal hysterectomy and bilateral salpingo-oophorectomy
(TAH/BSO)
66. A 48-year-old G0 woman presents to the office for preoperative
counseling. She has severe endometriosis that has failed medical
management, and she is planning to undergo a robotic total
hysterectomy and salpingo-oophorectomy. She is concerned
about developing a "dropped bladder" following her surgery,
since both her mother and aunt have undergone surgery for this
condition. She reports no urinary incontinence or other urinary or
bowel symptoms. She is in good health and exercises with
running and weight lifting. Pelvic examination reveals a well-
estrogenized vagina, a normal nulliparous cervix, anteverted
uterus, and mildly tender adnexa without masses. Which of the
following is likely to increase her risk of subsequent
development of pelvic organ prolapse?
B. Risk factors for the development of pelvic organ prolapse
are increasing parity, increasing age, obesity, some connective
tissue disorders (Ehlers-Danlos syndrome), and chronic
constipation. Vaginal delivery is associated with a higher risk of
POP than Cesarean delivery. It is unclear whether occupations
that require heavy lifting increase the risk of POP. Women with a
family history of POP have up to a 2.5 fold increase in prolapse.
Although hysterectomy is associated with an increased risk of
apical prolapse, studies show mixed results on the role of
hysterectomy in the development of prolapse. The risk of future
prolapse may be highest when hysterectomy is performed in
women with existing prolapse, while the risk in women with
normal pelvic support is less clear.

A. Age
B. Family History
C. Endometriosis
D. Exercising
E. Hysterectomy
67. A 48-year-old G4P4 woman with last menstrual period four weeks ago
presents with a one-year history of non-cyclical pelvic pain, dysmenorrhea
and dyspareunia. She has a past history of endometriosis, diagnosed 10
years ago by laparoscopy. She had previously been on oral contraceptives
for birth control and menstrual cycle regulation, but elected for permanent
laparoscopic sterilization 14 months ago. Minimal endometriosis was noted at
the time of laparoscopy. She now has recurrent symptoms and desires
definitive treatment. Which of the following is the most appropriate surgical
option for this patient?A 48-year-old G4P4 woman with last menstrual
period four weeks ago presents with a one-year history of non-cyclical
pelvic pain, dysmenorrhea and dyspareunia. She has a past history of
endometriosis, diagnosed 10 years ago by laparoscopy. She had previously
been on oral contraceptives for birth control and menstrual cycle regulation,
but elected for permanent laparoscopic sterilization 14 months ago. Minimal
endometriosis was noted at the time of laparoscopy. She now has recurrent
symptoms and desires definitive treatment. Which of the following is the
most appropriate surgical option for this patient?
A. Hysteroscopy and dilation and curettage
B. Diagnostic laparoscopy
C. Hysterectomy with bilateral salpingo-oophorectomy
D. Endometrial ablation
E. Wedge resection of the ovaries
68. A 52-year-old G0 woman presents with long-standing vulvar and vaginal
pain and burning. She has been unable to tolerate intercourse with her
husband because of pain at the introitus. She has difficulty sitting for
prolonged periods of time or wearing restrictive clothing because of
worsening vulvar pain. She recently noticed that her gums bleed more
frequently. She avoids any topical over-the-counter therapies because they
intensify her pain. Her physical examination is remarkable for inflamed
gingiva and a whitish reticular skin change on her buccal mucosa. A fine
papular rash is present around her wrists bilaterally. Pelvic examination
reveals white plaques with intervening red erosions on the labia minora as
shown in below picture. A speculum cannot be inserted into her vagina
because of extensive adhesions. The cervix cannot be visualized. Which of
the following is the most likely diagnosis in this patient?
A. Squamous cell hyperplasia
B. Lichen sclerosus
C. Lichen planus
D. Genital psoriasis
E. Vulvar cancer
C. It is estimated that chronic pelvic pain is the
principal preoperative indication for 10-12% of
hysterectomies. Since the patient had a tubal
ligation and does not desire any more children, the
best option is removal of ovaries with or without a
hysterectomy. Repeat laparoscopy with treatment
of endometriosis and adhesions can be helpful;
however, the patient will continue to be at
increased risk of recurrent disease. An endometrial
ablation or wedge resection of ovaries alone would
not be very helpful in the setting of non-cyclical
pain.
C. Lichen planus is a chronic dermatologic disorder
involving the hair-bearing skin and scalp, nails, oral
mucous membranes and vulva. This disease
manifests as inflammatory mucocutaneous
eruptions characterized by remissions and flares.
The exact etiology is unknown, but is thought to be
multifactorial. Vulvar symptoms include irritation,
burning, pruritus, contact bleeding, pain and
dyspareunia. Clinical findings vary with a lacy,
reticulated pattern of the labia and perineum, with
or without scarring and erosions as well. With
progressive adhesion formation and loss of normal
architecture, the vagina can become obliterated.
Patients may also experience oral lesions, alopecia
and extragenital rashes. Treatment is challenging,
since no single agent is universally effective and
consists of multiple supportive therapies and
topical high potency corticosteroids.
69. A 54-year-old G2P2 presents for a health maintenance examination.
She has a history of breast cancer treated with mastectomy with
reconstruction, chemotherapy, and is currently on tamoxifen. She
has been in remission for two years and has been menopausal since
the initiation of her chemotherapy. She experiences very mild hot
flashes and is not sleeping well. She appears apprehensive during
the examination, although her examination is completely normal
except for some mild vaginal atrophy. At the conclusion of the
office visit, she finally opens up and admits that she has a new
boyfriend after having gone through a divorce five years earlier.
She is anxious about initiating sexual activity again and wants your
advice on what she should do. Which of the following is likely
contributing to her anxiety?
A. Breast cancer diagnosis
B. Menopausal symptoms
C. Body image
D. Vaginal atrophy
E. All of the above
70. A 54-year-old G2P2 presents for her health maintenance
examination. She has a history of breast cancer treated with
mastectomy with reconstruction, chemotherapy, and is currently on
tamoxifen. She has been in remission for two years and has been
menopausal since the initiation of her chemotherapy. She
experiences very mild hot flashes, and is not sleeping well. She
appears apprehensive during the examination, although her
examination is completely normal except for severe vaginal
atrophy. At the conclusion of the office visit, she finally opens up
and admits that she has a new boyfriend. She has not had a sexual
relationship since her divorce five years earlier, but has been
enjoying masturbation. Although excited about initiating sexual
activity again, she is obviously concerned. Which of the following is
most likely to contribute to sexual dysfunction?
A. Sexual desire
B. Arousal
C. Orgasm
D. Dyspareunia
E. Body image
71. A 54-year-old woman presents with a breast mass she noticed two
months ago. She has no family history of breast cancer. On exam,
there is a 2 cm mass palpable in the upper outer quadrant of the
left breast. There are no other masses noted and no palpable
lymphadenopathy. A fine needle aspiration returns bloody fluid
and reduces the size of the mass to 1 cm. In addition to obtaining a
mammogram, what is the most appropriate next step in the
management of this patient?
A. Repeat exam in two months
B. Excisional biopsy of the mass
C. Obtain a breast MRI
D. Perform a lumpectomy and lymph node dissection
E. Follow-up in one year if mammogram is normal
E. Taking a good sexual history is critical to understanding
the root cause of a woman's concerns about possible sexual
dysfunction. Etiologies may be physiologic, hormonal,
psychologic, and often multifactorial. To distinguish among
these causes, a thorough inquiry into a woman's hormonal,
sexual, medical, and social history is necessary. A sexual
history must include a non-judgemental and candid
discussion related to her interests, desires, and practices to
better understand potential causes for concern and
dysfunction.
D. Female sexual dysfunction can be classified as disorders in
sexual desire, arousal, orgasm, or sexual pain, and can
include any combination of these. In this case, because she
states a desire to initiate in sexual activity and has been
enjoying masturbation, it is unlikely that she will experience
any problems related to desire, arousal, or orgasm. However,
in the presence of severe atrophy and lack of estrogen, she
may in fact experience pain related to dyspareunia. She
should be encouraged to use some form of water-based
lubricant to diminish the effects of the vaginal dryness since
estrogen is likely contraindicated with her breast cancer
diagnosis. Although body image may play a role, it would be
classified under the category of sexual desire.
B. The first noticeable symptom of breast cancer is typically a
lump that feels different from the rest of the breast tissue.
More breast cancer cases are discovered when the woman
feels a lump. Breast cancer can also present with a
spontaneous bloody nipple discharge. Even though the mass
decreased in size after aspiration, the bloody discharge
obtained obligates an excisional biopsy be performed to rule
out breast cancer. If clear discharge is obtained on aspiration
and the mass resolves, reexamination in two months is
appropriate to check that the cyst has not recurred. An MRI
is not the appropriate next step and lumpectomy with lymph
node dissection is not yet indicated in this case. A normal
mammogram does not rule out breast cancer, especially in
the presence of bloody discharge.
72. A 56-year-old G3P3 woman presents to the office
for her annual health maintenance examination.
She is in good health and is not taking any
medications. She has been postmenopausal for
three years. She had an abnormal Pap test 10 years
ago, but results have been normal every year
since. She is sexually active with her husband. On
examination, her cervix is 1 cm above the vaginal
introitus and there is moderate bladder prolapse.
Her uterus is normal in size and she has no adnexal
masses or tenderness. In addition to
recommending a mammogram, what is the most
appropriate next step in the management of this
patient?
A. Cystocele repair
B. Pelvic ultrasound
C. Total hysterectomy
D. Observation
E. Topical estrogen
73. A 57-year-old G2P2 is seen for a routine visit. She
states she and her 75-year-old husband stopped
having sexual intercourse three years ago when he
had an operation for prostate cancer. Menopause
occurred at age 50 and she denies taking
hormones. Her husband now wishes to resume
intercourse and is able to get an erection with
sildenafil (Viagra). Attempts at intercourse have
been unsuccessful due to the pain she experiences
when insertion is attempted. Examination is normal
except for a narrowed vagina with atrophic
mucosa. Which of the following is the most
appropriate recommendation at this time?
A. Progesterone cream
B. Estrogen cream
C. Oral combined hormone therapy
D. Petroleum jelly
E. Vaginal dilators
74. A 57-year-old G2P2 woman presents with a six-
month history of urinary incontinence, urgency,
and nocturia. She describes the amount of urine
loss as large and lasting for several seconds. The
urine loss occurs when she is standing or sitting
and is not associated with any specific activity. A
post-void residual is 50cc. What is the most likely
cause of this patient's symptoms?
A. Stress incontinence
B. Overflow incontinence
C. Urge incontinence
D. Mixed incontinence
E. Vesicovaginal fistula
D. This patient is asymptomatic from her prolapse; therefore, no intervention is
necessary at this point. Cystocele repairs and hysterectomies are invasive
procedures which are not indicated in this asymptomatic patient. It is not
necessary to obtain a pelvic ultrasound, as her uterus is normal in size and she
has no adnexal masses. Topical estrogen would not help improve the
prolapse, although it might help with her vaginal dryness. She seems to be
doing well with the lubricants and it is not necessary to expose her to
estrogen.
B. The patient is not on hormone replacement therapy. With decreased
estrogen production after menopause, the vaginal mucosa and other
estrogen-dependent tissues can become atrophic. Topical estrogen therapy
can restore the integrity of the vaginal epithelium, as well as the support
tissues around the vagina. Long-term use may require addition of a progestin
due to potential systemic absorption and effect on the endometrium.
Dyspareunia (pain with intercourse) can often be improved with the use of
estrogen cream used vaginally. Water based lubricants may be helpful, but
petroleum jelly is contraindicated because it can cause irritation of the vaginal
mucosa. This patient does not have any other menopausal symptoms that
would be treated by oral combination HRT. Oral progesterone may help to
decrease hot flushes, but progesterone cream would not alleviate vaginal
atrophy.
C. This patient has urge incontinence, which is caused by overactivity of the
detrusor muscle resulting in uninhibited contractions, which cause an increase
in the bladder pressure over urethral pressure resulting in urine leakage. Stress
incontinence is caused by an increase in intra-abdominal pressure (coughing,
sneezing) when the patient is in the upright position. This increase in pressure
is transmitted to the bladder that then rises above the intra-urethral pressure
causing urine loss. Associated structural defects are cystocele or urethrocele.
Overflow incontinence is associated with symptoms of pressure, fullness, and
frequency, and is usually a small amount of continuous leaking. It is not
associated with any positional changes or associated events. Mixed
incontinence occurs when increased intra-abdominal pressure causes the
urethral-vesical junction to descend causing the detrusor muscle to contract.
A vesicovaginal fistula typically results in continuous loss of urine.
75. A 60-year-old G2P2 woman presents with complaints of urinary
frequency and urge incontinence. Past medical history is
unremarkable. She is on no medications. Pelvic examination reveals
no evidence of pelvic relaxation. Post void residual is normal. Urine
analysis is negative. A cystometrogram reveals uninhibited detrusor
contractions upon filling. Which of the following is the best
treatment for this patient?
A. Amitriptyline
B. Oxybutynin
C. Topical (vaginal) estrogen
D. Pseudoephedrine
E. Kegel exercises
76. A 60-year-old G4P4 woman presents with a two-year history of
urine leakage with activity such as coughing, sneezing and lifting.
Her past medical history is significant for vaginal deliveries of
infants over 9 pounds. She had a previous abdominal hysterectomy
and bilateral salpingo-oophorectomy for uterine fibroids. She is on
vaginal estrogen for atrophic vaginitis. Physical examination reveals
no anterior, apical or posterior wall vaginal prolapse. The vagina is
well-estrogenized. Post-void residual is normal. Q-tip test shows a
straining angle of 60 degrees from the horizontal. Cough stress test
shows leakage of urine synchronous with the cough.
Cystometrogram reveals the absence of detrusor instability. The
patient failed pelvic muscle exercises and is not interested in an
incontinence pessary. Which of the following is the best surgical
option for this patient?
A. Retropubic urethropexy
B. Needle suspension
C. Anterior repair
D. Urethral bulking procedure
E. Colpocleisis
77. A 62-year-old G5P5 woman presents with a seven-month history of
pelvic pain and pressure, as well as abdominal distention and
bloating. She experiences occasional constipation, but no melena
or hematochezia. She also has mild to moderate urinary frequency
without dysuria, hematuria or flank pain. Her medical history is
significant for hypertension and obesity. She went through
menopause 12 years ago and has never been on hormone therapy.
She reports one episode of light vaginal bleeding several months
ago. Her family history is significant for postmenopausal ovarian
cancer in her mother and maternal aunt, but is otherwise negative
for breast, endometrial or colon cancer. Pelvic examination is
remarkable for vaginal atrophy, cervical stenosis and difficult
uterine and adnexal assessment due to her body habitus. What is
the most appropriate next step in the management of this patient?
A. Transvaginal ultrasound
B. CT scan of the abdomen and pelvis
C. Colonoscopy
D. Hysteroscopy
E. Diagnostic laparoscopy
B. The patient has the diagnosis of detrusor instability. The
parasympathetic system is involved in bladder emptying and
acetylcholine is the transmitter that stimulates the bladder to
contract through muscarinic receptors. Thus, anticholinergics
are the mainstay of pharmacologic treatment. Oxybutynin is
one example. Although the tricyclic antidepressant,
amitriptyline, has anticholinergic properties, its side effects
do not make it an ideal choice. Vaginal estrogen has been
shown to help with urgency, but not urge incontinence.
Pseudoephedrine has been shown to have alpha-adrenergic
properties and may improve urethral tone in the treatment of
stress incontinence. Kegel exercises or pelvic muscle training
are used to strengthen the pelvic floor and decrease urethral
hypermobility for the treatment of stress urinary
incontinence.
A. Genuine stress incontinence (GSI) is the loss of urine due
to increased intra-abdominal pressure in the absence of a
detrusor contraction. The majority of GSI is due to urethral
hypermobility (straining Q-tip angle >30 degrees from
horizon). Some (<10%) of GSI is due to intrinsic sphincteric
deficiency (ISD) of the urethra. Patients can have both
hypermobility and ISD. Retropubic urethropexy such as
tension-free vaginal tape and other sling procedures have
the best five-year success rates for patients with GSI due to
hypermobility. Needle suspensions and anterior repairs have
lower five-year success rates for GSI. Urethral bulking
procedures are best for patients with ISD, but with little to no
mobility of the urethra. Colpocleisis is one option to treat
uterine prolapse, and is not indicated for urinary
incontinence.
A. Given the patient's age, nonspecific abdomino-pelvic
symptoms, recent postmenopausal bleeding episode and
family history of ovarian cancer, a transvaginal ultrasound is
the next best step as it is more sensitive than CT for
evaluation of the uterus and adnexa. Colonoscopy is useful
for colorectal cancer screening, as well as evaluation of the
patient's gastrointestinal symptoms, but would not provide
information regarding pelvic anatomy. Diagnostic
laparoscopy would be a more invasive procedure that could
be performed as indicated, after these other diagnostic
studies. Hysteroscopy might be useful based on the
ultrasound results, since it might be difficult to perform an
endometrial biopsy in the office.
78. A 64-year-old G2P2 woman presents with a 12-month
history of severe vulvar pruritus. She has applied
multiple over-the-counter topical therapies without
improvement. She has no significant vaginal discharge.
She has severe dyspareunia at the introitus and has
stopped having intercourse because of the pain. Her
past medical history is significant for allergic rhinitis and
hypertension. On pelvic examination the external
genitalia show loss of the labia minora with resorption of
the clitoris (phimosis). The vulvar skin appears thin and
pale and involves the perianal area as in the picture
below. No ulcerations are present. The vagina is mildly
atrophic, but appears uninvolved. Which of the following
is the most likely diagnosis in this patient?
A. Squamous cell hyperplasia
B. Lichen sclerosus
C. Lichen planus
D. Candidiasis
E. Vulvar cancer
79. A 65-year-old G3P3 woman presents with symptoms of
vaginal pressure and heaviness, which seem to worsen
towards the end of the day. She has a history of three
vaginal deliveries. Her surgical history is significant for
hysterectomy for abnormal vaginal bleeding at age 45.
On exam, she is found to have a large pelvic prolapse.
Which of the following is the most appropriate initial
treatment of this patient's prolapse?
A. Sacrospinous ligament suspension
B. Transvaginal tape
C. Pessary fitting
D. Anterior repair
E. Topical vaginal estrogen
80. A 67-year-old G3P3 woman presents with severe pelvic
protrusion several years following an abdominal
hysterectomy. She denies any incontinence. She failed
conservative management with a pessary. As a result,
she underwent a vaginal surgical repair where the
pubocervical fascia was plicated in the midline, as well
as laterally to the arcus tendineus fascia (white line).
What defect was repaired in this patient?
A. Cystocele
B. Rectocele
C. Uterine prolapse
D. Enterocele
E. Urethral diverticulum
B. Lichen sclerosus is a chronic inflammatory skin condition that most
commonly affects Caucasian premenarchal girls and postmenopausal
women. The exact etiology is unknown, but is most likely multifactorial.
Patients typically present with extreme vulvar pruritus and may also
present with vulvar burning, pain and introital dyspareunia. Early skin
changes include polygonal ivory papules involving the vulva and
perianal areas, waxy sheen on the labia minora and clitoris, and
hypopigmentation. The vagina is not involved. More advanced skin
changes may include fissures and erosions due to a chronic itch-scratch-
itch cycle, mucosal edema and surface vascular changes. Ultimately,
scarring with loss of normal architecture, such as introital stenosis and
resorption of the clitoris (phimosis) and labia minora, may occur.
Treatment involves use of high-potency topical steroids. There is less
than a 5% risk of developing squamous cell cancer within a field of lichen
sclerosus.
C. Pessary fitting is the least invasive intervention for this patient's
symptomatic prolapse. Although a sacrospinous ligament suspension
would be an appropriate procedure for this patient, it is invasive and not
an appropriate first step. Transvaginal tape is used for urinary
incontinence and has no role in the management of this patient. An
anterior repair can potentially help with her symptoms, depending on
what is contributing most to her prolapse but, again, it is invasive. Topical
estrogen is unlikely to properly treat her prolapse and related symptoms.
A. Central and lateral cystoceles are repaired by fixing defects in the
pubocervical fascia or reattaching it to the sidewall, if separated from the
white line. Defects in the rectovaginal fascia are repaired in rectoceles.
Uterine prolapse is surgically treated by a vaginal hysterectomy, but this
patient already had a hysterectomy. Enteroceles are repaired by either
vaginal or abdominal enterocele repairs. Vaginal vault prolapse is treated
either by supporting the vaginal cuff to the uterosacral or sacrospinous
ligaments, or by sacrocolpopexy. Urethral diverticulum does not present
with severe pelvic protrusion.
81. A 68-year-old G3P3 woman comes to the office due to breast
tenderness. She is in good health and not taking any
medications. Family history is significant for her 70-year-old
sister recently diagnosed with breast cancer. On breast
examination, her breasts have no lesions; there are no
palpable masses, nodules or lymphadenopathy. Her last
mammogram was four months ago and was normal. What is
the most appropriate next step in the management of this
patient?
A. Order a mammogram
B. Order a breast ultrasound
C. Obtain genetic testing (BRCA-1 and BRCA-2 mutations)
D. Reassurance
E. Order a breast MRI
82. A 70-year-old G3P3 woman presents with a four-year history
of constant leakage of urine. Her history is significant for
abdominal hysterectomy and bilateral salpingo-
oophorectomy for endometriosis. She had two anterior
repairs in the past for recurrent cystocele. The leakage
started six months after her last anterior repair. Pelvic
examination reveals no evidence of pelvic relaxation. The
vagina is well-estrogenized. Q-tip test reveals a fixed,
immobile urethra. Cystometrogram shows no evidence of
detrusor instability. Cystourethroscopy showed no evidence
of any fistula and reveals a "drain pipe" urethra. Which of the
following is the best first treatment for this patient?
D. Age and gender are the greatest risk factors for developing
breast cancer. Having one first-degree relative with breast cancer
does increase the risk. A women's risk of developing breast cancer
before menopause is increased if she is BRCA-1 or BRCA-2 positive;
however, these genetic mutations occur in a low percentage of the
general population. There is no indication for a mammogram since
the patient's last mammogram was normal four months ago.
Ultrasound and MRI would not add valuable information especially
in the setting of a normal mammogram and no masses on physical
examination. Genetic testing is not indicated in this case as there is
no strong family history and the sister with breast cancer was
postmenopausal at time of diagnosis.
D. This is a classic example of intrinsic sphincteric deficiency.
Urethral bulking procedures are minimally invasive and have a
success rate of 80% in these specific patients. The success rates for
retropubic urethropexies, needle suspension and slings are less
than 50%. An "obstructive or tight" sling can be performed to
increase the success rate, but the voiding difficulties are significant,
even requiring prolonged or lifelong self-catheterization. Artificial
sphincters should be used in patients as a last resort.

A. Retropubic urethropexy
B. Needle suspension
C. Artificial urethral sphincter
D. Urethral bulking procedure
E. Sling procedure
83. A 74-year-old G0 woman complains of vulvar pain. She C. This patient has a vulvar lesion causing her pain. The next step is
reports that the pain is present every day and she has had it to perform a biopsy to evaluate for vulvar cancer. Estrogen cream
for the past year. It now limits her ability to exercise, and she and clobetasol (a high potency steroid) are treatments for
is no longer able to have sexual relations with her partner. vulvadynia. To diagnosis vulvadynia, all other causes of pain must
On exam, her BMI is 32; blood pressure is 100/60; and heart first be excluded, including infectious etiologies as well as other
rate is 77. Her vulva has an ulcerated lesion near the left vulvar conditions. Laser vaporization and vulvectomy are
labial edge. Which of the following is the next best step in the contraindicated until a definitive diagnosis is made.
management of this patient?

A. Estrogen cream
B. Clobetasol cream
C. Vulva biopsy
D. Laser vaporization of the lesion
E. Vulvectomy
84. A 76-year-old G3P3 woman presents to your office with
worsening urinary incontinence for the past three
months. She reports increased urinary frequency,
urgency and nocturia. On examination, she has a mild
cystocele and rectocele. A urine culture is negative. A
post-void residual is 400 cc. Which of the following is
the most likely diagnosis in this patient?
A. Genuine stress incontinence
B. Detrusor instability
C. Overflow incontinence
D. Functional incontinence
E. Mixed incontinence
85. A 90-year-old G7P7 woman presents with severe
vaginal prolapse. The entire apex, anterior and
posterior wall are prolapsed beyond the introitus. She
cannot urinate without reduction of the prolapse.
Hydronephrosis is noted on ultrasound of the kidneys
and thought to be related to the prolapse. She has a
long-standing history of diabetes and cardiac disease.
She has failed a trial of pessaries. Which of the
following is the next best step in the management of
this patient?
A. Do nothing and observe
B. Anterior and posterior repair
C. Colpocleisis
D. Sacrospinous fixation
E. Sacrocolpopexy
C. Overflow incontinence is characterized by failure to empty the
bladder adequately. This is due to an underactive detrusor muscle
(neurologic disorders, diabetes or multiple sclerosis) or obstruction
(postoperative or severe prolapse). A normal post-void residual (PVR) is
50-60 cc. An elevated PVR, usually >300 cc, is found in overflow
incontinence. Stress incontinence occurs when the bladder pressure is
greater than the intraurethral pressure. Overactive detrusor contractions
can override the urethral pressure resulting in urine leakage. The mixed
variety includes symptoms related to stress incontinence and urge
incontinence.
C. Because of the hydronephrosis due to obstruction, intervention is
required. Colpocleisis is a procedure where the vagina is surgically
obliterated and can be performed quickly without the need for general
anesthesia. Anterior and posterior repairs provide no apical support of
the vagina. She will be at high risk of recurrent prolapse. The
sacrospinous fixation (cuff to sacrospinous-coccygeus complex) or
sacrocolpopexy (cuff to sacral promontory using interposed mesh)
require regional or general anesthesia and is not the best option for this
patient with high surgical morbidity.
 Unit 4: REI
Study online at quizlet.com/_2irwfn

1. A 4-year-old female is being
evaluated for premature hair growth
in the pubic area. She has no breast
development and has not had any
menstrual bleeding. Laboratory
evaluation revealed high DHEA and
DHEAS levels and low levels of LH
and FSH. Which of the following is
the most likely cause of this patient's
premature adrenarche?
B. Congenital adrenal hyperplasia of the 21-hydroxylase type results in the adrenal being
unable to produce adequate cortisol as a result of a partial block in the conversion of 17-
hydroxyprogesterone to desoxycorticosterone, with the accumulation of adrenal androgens.
This leads to precocious adrenarche. Treatment includes steroid replacement. Idiopathic
isosexual precocious puberty is GnRH dependent and leads to an appropriate (although
early) order of pubertal events. Some girls with premature adrenarche develop polycystic
ovarian syndrome in adolescence, but not at this age.

A. Idiopathic isosexual precocious

puberty
B. Congenital adrenal hyperplasia
C. Hypothalamic dysfunction
D. Pituitary adenoma
E. Polycystic ovarian syndrome
2. A 7-year-old female is undergoing
evaluation for vaginal bleeding. On
physical examination, she has Tanner
stage III breasts, tall stature and an
otherwise normal examination. An
MRI of the brain and a pelvic
ultrasound are normal. LH and FSH
levels are in the pubertal levels and
she has normal DHEAS and
androgen levels. What is the most
likely diagnosis in this patient?
C. True precocious puberty is a diagnosis of exclusion where the sex steroids are increased
by the hypothalamic-pituitary-gonadal axis, with increased pulsatile GnRH secretion. CNS
abnormalities associated with precocious puberty include the following: tumors (e.g.,
astrocytomas, gliomas, germ cell tumors secreting human chorionic gonadotropin [hCG]);
hypothalamic hamartomas; acquired CNS injury caused by inflammation, surgery, trauma,
radiation therapy, or abscess; or congenital anomalies (e.g. hydrocephalus, arachnoid cysts,
suprasellar cysts). These conditions are not likely in the presence of a normal work-up in this
patient. Congenital adrenal hyperplasia usually presents in the neonatal period and is
associated with ambiguous genitalia. McCune Albright Syndrome is characterized by
premature menses before breast and pubic hair development. An ovarian neoplasm is unlikely
with a normal pelvic ultrasound.

A. Pituitary adenoma
B. Congenital adrenal hyperplasia
C. True precocious puberty
D. McCune Albright Syndrome
E. Ovarian neoplasm
3. An 8-year-old female has been B. True precocious puberty is manifested by premature secretion of GnRH hormone in a
diagnosed with precocious puberty pulsatile manner. Once other causes of hormone production are ruled out, treatment would
due to presence of menarche, Tanner include GnRH agonist to suppress pituitary production of follicular-stimulating hormone and
stage III breasts and otherwise luteinizing hormone. Observation is acceptable if the precocious puberty is within a few
normal work-up for brain, adrenal months of the routinely expected puberty. The process should be treated if the bone age or
and ovarian abnormalities. What is puberty is advanced by several years.
the most appropriate next step in the
management of this patient?

A. Depo-Provera
B. GnRH agonist
C. Danazol
D. Estradiol
E. Observation
4. A 9-year-old female goes to the doctor's office for a regular
check-up. She is healthy, active in school sports and gets good
grades. On examination she is 4 feet 8 inches tall and weighs
80 pounds. She is concerned about when she might expect to
have her first menstrual period since her friends have been
talking about it. On physical examinations, she has Tanner
stage 1 breasts and no pubic hair. You explain to her that she
can expect to experience which of the following first sexual
developments?
A. Adrenarche
B. Thelarche
C. Growth spurt
D. Menarche
E. Pubarche
5. A 13-year-old female is brought to the physician for
increasingly severe abdominal pain. The pain is now constant
and mildly uncomfortable, but every month she has a week
when it is more severe. She has Tanner stage II breasts and
pubic hair development. On genital examination, there is a
bluish mass pushing the labia open. What is the most likely
cause of this patient's abdominal pain?
A. Turner's syndrome
B. Transverse vaginal septum
C. Isolated atresia of the cervix
D. Imperforate hymen
E. Synechiae of the uterine cavity
6. A 14-year-old G0 female reports menarche six months ago,
with increasingly heavy menstrual flow causing her to miss
several days of school. Three months ago, her pediatrician
started her on oral contraceptives to control her menstrual
periods, but she continues to bleed heavily. Her previous
medical history is unremarkable. The patient has a normal
body habitus for her age. Appropriate breast and pubic hair
development is present. Her hemoglobin is 9.1 mg/dl,
hematocrit 27.8%, a urine pregnancy test is negative. Which of
the following etiologies for menorrhagia is most likely the
cause of her symptoms?
A. Uterine leiomyoma
B. Thyroid disorder
C. Coagulation disorder
D. Endometrial hyperplasia
E. Chronic endometritis
B. The normal and predictable sequence of sexual maturation
proceeds with breast budding, then adrenarche (hair growth), a
growth spurt and then menarche. In a minority of cases, pubarche
(pubic hair growth) can occur before thelarche (breast/areolar
development). Breast development begins around the age of 10
and average age of menarche is 12.7 years for Caucasian girls and
12.1 for Black girls. Menarche also occurs earlier for heavier girls
and later for thinner, physically active girls.
D. Lower genital tract malformations occur in 1 in 10,000 females
and are most commonly an imperforate hymen where the genital
plate canalization is incomplete. Amenorrhea and abdominal pain
are also associated with isolated atresia of the vagina or cervix.
The menstrual blood will collect in the vagina and uterus causing
pain. Treatment involves surgical correction. When a transverse
vaginal septum is present, a normal vaginal opening with a short
blind vagina and pelvic mass may be located above the level of
the obstruction found on exam. Asherman's syndrome is
associated with secondary amenorrhea resulting from intrauterine
scarring/synechiae.
C. Disorders of clotting may present with menstrual symptoms in
young women, with Von Willeberand disease being most common.
Leiomyomas typically present in women in their 30's and 40's.
Endometrial hyperplasia can occur in younger anovulatory
patients, but the short duration of this patient's symptoms makes
this less likely. She does not have any signs of infection or thyroid
disease.
7. A 15-year-old female mentions to her doctor that she C. Normal age for menarche is between nine and 17. Since this patient has
has never had a menstrual cycle. She is healthy, active secondary sexual characteristics and normal anatomy, she should be
in school activities and eats a normal diet. She denies offered reassurance that she is normal and her menses will probably start
ever being sexually active. On physical examination, soon.
she has Tanner stage II breast and pubic hair growth,
and average weight and height. Vaginal opening is
present and appears normal. What is the most
appropriate next step in her management?

A. Pelvic ultrasound
B. Oral contraceptive pills
C. Reassurance
D. MRI of sella turcica
E. Cortisol challenge test
8. A 15-year-old G0 female presents with severe A. The progestin in oral contraceptives causes endometrial atrophy. Since
menstrual pain for the past 12 months. The pain is prostaglandins are produced in the endometrium, there would be less
severe enough for her to miss school. The pain is not produced. Dysmenorrhea should be improved.
relieved with ibuprofen 600 mg every four hours. She
is not sexually active and the workup reveals no
pathology. Which mechanism of action best explains
why oral contraceptives would be the most
appropriate treatment for this patient?

A. Inducing endometrial atrophy

B. Decreasing inflammation
C. Increasing prolactin levels
D. Decreasing inhibin levels
E. Thickening cervical mucous
9. A 16-year-old female comes to the doctor to discuss
contraception. She recently became sexually active
and states she has never had a menstrual cycle. She
regularly attends school and participates in the band.
On physical examination, she is 5 feet 3 inches tall and
weighs 130 pounds. She has no secondary sexual
characteristics with normal appearing external
genitalia. The physician suspects Kallmann syndrome.
Which of the following diagnostic tests will help
confirm the diagnosis?
B. Kallmann syndrome is characterized by olfactory tract hypoplasia and the
arcuate nucleus does not secrete GnRH. Therefore, these females have no
sense of smell and do not develop secondary sexual characteristics. The
diagnosis is often one of exclusion found during the workup of delayed
puberty. The presence of anosmia with delayed puberty should suggest
Kallmann syndrome. Treatment is pulsatile GnRH therapy. Testosterone
levels would be needed if the patient had symptoms of male hormone
(androgen) production such as excess hair growth, male pattern baldness,
or clitoris enlargement. Cortisol levels are obtained if you suspect adrenal
or pituitary gland problems.

A. MRI of the pituitary

B. Olfactory challenge
C. Measurement of testosterone levels
D. Pelvic ultrasound
E. Cortisol levels
10. A 16-year-old female goes to the doctor to discuss why she has
not had a menstrual cycle. She is healthy and plays weekend
volleyball. She studies hard and gets good grades in school. She
has a good relationship with her parents. On examination she is 5
feet 1 inch tall and weighs 80 pounds. Breast and pubic hair growth
are at a Tanner stage II. External genital examination is normal.
What is the most likely reason this patient has not had any
menses?
A. Inadequate body weight
B. Poor nutrition
C. Inadequate sleep
D. Excessive exercise
E. Familial reasons
11. A 17-year-old female is brought to the physician because she has
never had a menstrual cycle. She has normal breast and pubic hair
development. Physical examination reveals a small vaginal
opening with a blind pouch. Pelvic ultrasound reveals normal
ovaries, but absence of uterus and cervix. Which of the following is
the most appropriate next study in this patient?
A. Renal ultrasound
B. Brain MRI
C. FSH and LH determination
D. Cortisol level
E. Testosterone level
12. A 17-year-old G0 female is brought in by her mother because she
has not yet had any menses. She is otherwise in good health, but
recently has been experiencing cyclical lower abdominal
cramping. She has never had sexual intercourse. She is 5 feet 6
inches tall and weighs 120 pounds. On examination, her breasts are
Tanner Stage IV. She has some suprapubic tenderness on
abdominal exam. Her pelvic exam reveals normal external
genitalia, but there was difficulty inserting a speculum due to
patient's discomfort. Beta-hCG < 5 mIU/mL. What is the most likely
diagnosis in this patient?
A. Genital tract outflow obstruction
B. Mllerian agenesis
C. Hypothalamic-pituitary dysfunction
D. Psychogenic amenorrhea
E. Constitutional delay in menarche
A. This patient does not weigh enough since a body weight of
85 to 106 pounds is needed before menses begins. There are
two other critical elements for secondary sexual
characteristics: sleep and optic exposure to sunlight. These
factors especially can delay the onset of menarche.
Psychosocial causes of delayed puberty include eating
disorders, excessive exercise (playing volleyball on the
weekend is not considered excessive exercise), and stress or
depression.
A. Renal anomalies occur in 25-35% of females with Mullerian
agenesis. The uterus and cervix are absent, but the ovaries
function normally and, therefore, secondary sexual
characteristics are present. You would expect the karyotype in
this patient to be 46,XX and testosterone levels in the female
range.
A. This patient's primary amenorrhea, with normal secondary
sexual characteristics, development and cyclical abdominal
pain, points to an anatomical cause of amenorrhea, which is
preventing menstrual bleeding. An imperforate hymen
commonly causes this and the treatment is surgical. In
Mllerian agenesis, or Mayer-Rokitansky-Kster-Hauser
syndrome, there is congential absence of the vagina and
usually an absence of the uterus and fallopian tubes. Ovarian
function is normal and all the secondary sexual characteristics
of puberty occur at the appropriate time.
13. A 17-year-old G0 female presents with hirsutism, irregular menses and
obesity. Her mother is moderately obese with mild hirsutism. Recently,
the patient's hirsutism has worsened and she has been depressed. She
has also gained 20 pounds in the past two months and has noticed
stretch marks on her abdomen. At the time of your examination, you
note that she has terminal hair growth on her chin and hair growth on
the back of her hands. Her cheeks appear flushed. Her stretch marks
are purplish in color. The rest of her exam is normal. Which of the
following is the most appropriate first test to order for this patient?
A. Overnight dexamethasone suppression test
B. 17-hydroxyprogesterone
C. Fasting insulin
D. TSH
E. Pelvic ultrasound
14. An 18-year-old G0 woman comes in for a health maintenance
examination with her mother. The mother had severe PMS symptoms in
her twenties and thirties and would like to know if her daughter would
inherit this as well. Which of the following has the strongest association
with premenstrual syndrome?
A. Obesity
B. Positive family history
C. History of early menarche
D. Insulin dependent diabetes mellitus
E. Vitamin K deficiency
15. An 18-year-old G0 woman comes to the office due to vaginal spotting
for the last two weeks. Her menstrual periods were regular until last
month, occurring every 28-32 days. Menarche was at age 13. She
started oral contraceptives three months ago. On pelvic examination,
the uterus is normal in size, slightly tender with a mass palpable in the
right adnexal region. No adnexal tenderness is noted. Which of the
following tests is the most appropriate next step in the management of
this patient?
A. Endometrial biopsy
B. Pelvic MRI
C. Pelvic ultrasound
D. Abdominal CT Scan
E. Urine pregnancy test
16. An 18-year-old G0 woman presents with a one-year history of hirsutism
and acne. She had menarche at age 14 and her menses have been
irregular every 26-60 days. Her sister has a similar pattern of hair
growth. The patient is 5 feet 4 inches tall and weighs 180 pounds. On
exam, a few terminal hairs were identified on her chin and upper lip.
TSH, prolactin, total testosterone, and DHEAS levels are normal. Which
of the following is the most appropriate next test to evaluate this
patient's condition?
A. Estradiol
B. Serum cortisol
C. Urinary cortisol
D. Random blood glucose
E. 17-hydroxyprogesterone
A. Since Cushing's syndrome is suspected, either a
dexamethasone suppression test or a 24-hour urinary
measurement for cortisol can be performed. Elevated
cortisol would be indicative of Cushing's syndrome. The
other tests listed would be reasonable, but only after
Cushing's syndrome had been excluded.
B. Risk factors for PMS include a family history of
premenstrual syndrome (PMS) and Vitamin B6, calcium, or
magnesium deficiency. PMS becomes increasingly
common as women age through their thirties, and
symptoms sometimes get worse over time. Previous
anxiety, depression or other mental health problems are
significant risk factors for developing premenstrual
dysphoric disorder (PMDD). There is no known
association between premenstrual syndrome and obesity
or insulin dependent diabetes mellitus.
E. It is vitally important to rule out pregnancy in the
evaluation of abnormal uterine bleeding. Pelvic
ultrasound could be considered as a next step if the
pregnancy test is negative in order to evaluate the
adnexal finding. Abdominal CT or MRI would not be
performed in this patient unless advanced adnexal
pathology was found on pelvic sonography. Endometrial
biopsy would rarely be indicated in a teen with abnormal
bleeding, unless morbidly obese and anovulatory.
E. Checking 17-hydroxyprogesterone would rule out late
onset 21-hydroxylase deficiency. Normal TSH, Prolactin,
total testosterone and DHEAS levels rule out pituitary or
adrenal tumors. The patient could have polycystic ovarian
syndrome; however, normal serum testosterone levels
make it less likely. Blood glucose would not help
determine the etiology of hisrsutism.
17. A 19-year-old G0 woman presents with severe
menstrual pain that causes her to miss school. She
takes 600 mg of ibuprofen every four to six hours to
control the pain, but this does not relieve the
discomfort. You started oral contraceptives, but her
symptoms persisted. She also tried Depo-Provera
for three months without much improvement. She
still has menstrual pain and continues to miss some
classes. What is the most appropriate next step in
the management?
B. Laparoscopy is recommended to confirm the diagnosis of endometriosis
and exclude other causes of secondary dysmenorrhea. SSRIs are not used to
treat dysmenorrhea, rather they are a good treatment for PMS. Some authors
suggest that a course of GnRH agonists are appropriate, with laparoscopy
reserved for those women who have pain during or after completion of a
three-month course, but using estrogen add-back would remove the
diagnostic sensitivity of the GnRH agonist.

A. Transdermal narcotic for pain relief

B. Diagnostic laparoscopy
C. Presacral neurectomy
D. Prescribe a selective serotonin reuptake inhibitor
E. Prescribe GnRH agonist with estrogen add-back
18. A 19-year-old G0 woman presents with severe C. Dysmenorrhea or painful menstrual cramps is often incapacitating. Oral
menstrual pain which causes her to miss school. She contraceptives will not only relieve primary dysmenorrhea, but also provide
takes 600 mg of ibuprofen every four to six hours to more reliable contraception. Copper IUD's have the potential to cause
control the pain, but this does not relieve the heavier and more painful periods. Continuous oral Medroxyprogesterone
discomfort. She is sexually active, with one partner may be effective, but will not provide contraception. Depo-Provera would be
(she has had two lifetime partners) and uses a better choice. GnRH agonists are too expensive and have too high a side
condoms for contraception. Examination is normal. effect profile to be used for this purpose.
What is the most appropriate next step in the
management of this patient?

A. Copper IUD
B. GnRH agonist
C. Oral contraceptives
D. Continuous medroxyprogesterone
E. Laparoscopy
19. A 20-year-old G0 woman presents with severe
menstrual pain. She takes 600 mg of ibuprofen
every four to six hours to control the pain, but this
does not relieve the discomfort. She is sexually
active with one partner and has four lifetime
partners. She uses condoms for contraception. Past
medical history is unremarkable, except for breast
cancer in her father's sister. Examination is normal.
Which of the following is the most appropriate test
for this patient?
B. The US Preventive Services Task Force recommends chlamydia and
gonorrhea screening for all sexually active patients, age 25 and younger.
Since pelvic inflammatory disease is a cause of secondary dysmenorrhea, it
needs to be evaluated as a potential cause of her symptoms. Although HPV
screening is common, it can be used as an adjunct to cytology in primary
screening in women 30 years or older, and is not indicated in a 20 year old.
Pap smears are not indicated in women under 21 years of age regardless of
sexual history. A hysterosalpingogram is used for infertility work-up and will
not necessarily help determine the cause of her pain. A diagnostic
laparoscopy would be premature at this point.

A. HPV DNA typing

B. Chlamydia testing
C. Pap smear
D. Hysterosalpingogram
E. Diagnostic laparoscopy
20. A 21-year-old G0 woman comes to the office because
of acne, irregular menses and hirsutism. She initially
was evaluated six months ago, at which time she was
diagnosed with idiopathic hirsutism. She was started
on oral contraceptive pills to improve her symptoms.
Menstrual periods now occur every month, but her
hirsutism has not significantly improved. In addition
to the oral contraceptives, which of the following
would be an appropriate treatment for hirsutism?
A. Spironolactone
B. Lupron
C. Danazol
D. Depo-Provera
E. Steroids
21. A 22-year-old G0 woman college student returns for
follow-up of mood swings and difficulty
concentrating on her schoolwork the week before
her menses for the past 12 months. Her past medical
history is unremarkable and physical examination is
normal. Which of the following would be an
appropriate treatment option for this patient?
A. Oral contraceptive pills
B. Reassurance and observation
C. Methylphenidate (Ritalin)
D. Gabapentin
E. Ginkgo
22. A 22-year-old G0 woman presents with five months
of amenorrhea since discontinuing her oral
contraceptive pills. She had been on the pill for the
last six years and had normal menses every 28 days
while taking them. She is in good health and not
taking any medications. She is 5 feet 4 inches tall and
weighs 140 pounds. Her examination, including a
pelvic examination, is normal. Which of the following
historical elements would be most useful in
determining the cause of amenorrhea in this patient?
A. Age at first intercourse
B. History of sexually transmitted infections
C. Parity
D. History of oligo-ovulatory cycles
E. Recent history of weight loss
A. Spironolactone, an aldosterone antagonist diuretic, can also be used in
addition to the oral contraceptives for hirsutism. Danazol is primarily used
for the treatment of endometriosis and may actually worsen hirsutism and
acne. Lupron and Depo-Provera are also reasonable as second-line
treatments of hirsutism, had the patient not already been on oral
contraceptives. Steroids will not help.
A. This woman has premenstrual syndrome (PMS) with symptoms that
warrant treatment. Patients with PMS and premenstrual dysphoric disorder
(PMDD) experience adverse physical, psychological and behavioral
symptoms during the luteal phase of the menstrual cycle. PMS is
characterized by mild to moderate symptoms, while PMDD is associated
with severe symptoms that seriously impair usual daily functioning and
personal relationships. Mild symptoms of PMS often improve by suppressing
the hypothalamic-pituitary-ovarian axis with oral contraceptive pills. Ritalin
and Ginkgo are not effective treatments for PMS. Gabapentin is used for
neuropathic pain and will not help alleviate her symptoms.
D.Since most women resume normal menstrual cycles after discontinuing
oral contraceptive pills (OCPs), they are not usually considered the cause of
the amenorrhea. A history of irregular cycles prior to pill use may increase
the risk of amenorrhea upon discontinuation. This is sometimes referred to
as "post pill amenorrhea." A complete work-up should be performed to
properly find the cause. Although the other historical elements are all
important components of a complete gynecological history, they are not
helpful to find the etiology of amenorrhea in this patient. Significant weight
loss might cause amenorrhea; however, this patient still has normal body
mass index, which makes it unlikely cause of amenorrhea.
23. A 22-year-old G0 woman presents with hirsutism which has been
present since menarche. She states that she has laser treatments
done to remove the hair on her chin every couple of months, and
was wondering if there are additional treatments which might help
her. She is otherwise in good health. She has normal menstrual
cycles every 28 days. She is sexually active and uses birth control
pills for contraception. The patient is adopted and has no
information about family history. She is 5 feet 4 inches tall and
weighs 125 pounds. On examination, the patient was noted to have
terminal hair growth on her chest. Her TSH, Prolactin, total
testosterone, DHEAS, 17-hydroxyprogesterone levels are normal.
Which of the following is the most likely underlying etiology for the
hirsutism in this patient?
A. Polycystic ovarian syndrome
B. Side effects of the oral contraceptives
C. Cushing's syndrome
D. Adrenal tumor
E. Idiopathic hirsutism
24. A 22-year-old G0 woman presents with painful menstruation that
limits her activities each month. She describes the pain as
spasmodic occurring on days one to three of bleeding since her
cycles began. Other symptoms include nausea, nervousness,
diarrhea, and headache. Her physical exam is normal with a soft,
non-tender abdomen. Bimanual exam reveals a fixed uterus with
uterosacral ligament nodularity. There are no adnexal masses
noted. Which of the following is the most likely diagnosis in this
patient?
A. Premenstrual syndrome
B. Premenstrual dysphoric disorder
C. Primary dysmenorrhea
D. Secondary dysmenorrhea
E. Adenomyosis
E. This patient most likely has idiopathic hirsutism. She has no
other clinical signs of polycystic ovaries, such as irregular
cycles or obesity. Normal laboratory values rule out other
pathogenic causes of hirsutism, such as Cushing's syndrome
or adrenal tumor. Oral contraceptives are actually used for
the treatment of hirsutism because they establish regular
menses and lower ovarian androgen production.
Additionally, they cause an increase in SHBG (sex hormone
binding globulin) which allows more testosterone to be
bound and unavailable at the hair follicle.
D. The physical examination in patients with primary
dysmenorrhea is normal. There should not be any palpable
abnormalities on abdominal, speculum, pelvic, bimanual, and
rectal examinations. The restricted uterine motion found on
exam suggests the possibility of endometriosis or pelvic
scarring from inflammation or adhesions. These conditions
must be considered in establishing the etiology of her
diagnosis. Childbearing does not affect the occurrence of
either diagnosis. Although the patient's symptoms, including
the associated symptoms, timing of initial onset, and cyclic
nature of her pain are consistent with primary dysmenorrhea,
the finding on physical examination makes secondary
dysmenorrhea the likely diagnosis.
25. A 23-year-old G0 woman comes to the clinic because she is
interested in becoming pregnant. She is in good health; however, she
has not had any menses for the last two years. She had menarche at
age 15, had normal periods until three years ago, when she started
having periods irregularly every three months until it stopped two
years ago. She has no history of pelvic infections or abnormal Pap
smears. She exercises every day by running and has run four
marathons in the last three years. She is 5 feet 10 inches tall and
weighs 115 pounds. Her examination including a pelvic exam is
normal. Laboratory results show:
E. This patient most likely has exercise-induced
hypothalamic amenorrhea, which is characterized by normal
FSH and low estrogen levels. The other studies will not help
determine the diagnosis. The best treatment is to encourage
the patient to gain weight by decreasing exercise and
increasing caloric intake. If her menses fail to resume, she
may be treated with exogenous gonadotropins (LH and
FSH) to help her conceive. Clomiphene citrate tends not to
work as well, due to the baseline hypoestrogenic state.

Results Normal Values

TSH 3.5 mIU/ml 0.5-4.0 mIU/ml
Free T4 0.9 ng/dl 0.8-1.8 ng/dl
Prolactin 10 ng/ml <20 ng/ml
FSH 6 mIU/ml 5-25 mIU/ml
LH 4 mIU/ml 5-25 mIU/ml
BHCG 2 mIU/ml <5 mIU/ml
What is the most appropriate next step in the evaluation of this
patient?

A. Check cortisol levels

B. Order a brain MRI
C. Obtain a pelvic ultrasound
D. Check testosterone levels
E. Check estrogen levels
26. A 23-year-old G0 woman presents to the office because she has not C. Oral contraceptives (OCPs) are the most appropriate
had any menses for four months. She has a long history of irregular treatment for this patient who most likely has the diagnosis
menstrual cycles since menarche at age 14. She is in good health and of polycystic ovarian syndrome (PCOS). The constellation of
is not taking any medications. She is sexually active with her partner findings support this clinical diagnosis (irregular cycles,
of six months, and uses condoms for contraception. She is 5 feet 4 obesity, and hirsutism). Because she is using condoms for
inches tall and weighs 170 pounds. On exam, she has noticeable hair contraception and is sexually active, OCPs would help
growth on her upper lip and chin. The rest of her examination regulate her cycles and further provide effective
including a pelvic examination is normal. Her Beta-hCG is < 5 contraception. When she desires pregnancy, however, she
mIU/mL, and her prolactin and TSH levels are normal. In addition to will most likely need treatment for ovulation induction due
recommending weight loss, what is the most appropriate next step in to the anovulatory cycles as the leading cause of her
the management of this patient? oligomenorrhea. Clomiphene citrate is not indicated at this
time.
A. Treatment with gonadotropin releasing hormone level (GnRH)
agonist
B. Treatment with clomiphene citrate
C. Treatment with oral contraceptives
D. Check progesterone levels
E. Check cortisol levels
27. A 23-year-old G0 woman presents to the office because
she has not had any menses for four months. She has a
long history of irregular menstrual cycles since
menarche at age 14. She is otherwise in good health and
is not taking any medications. She is thin and has
chronic anxiety (BMI 16). Her Beta-hCG is < 5 mIU/mL,
and her prolactin and TSH levels are normal. What
would be the next best diagnostic test to order?
D. The causes of hypothalamic-pituitary amenorrhea are functional
(weight loss, obesity, excessive exercise), drugs (marijuana and
tranquilizers), neoplasia (pituitary adenomas), psychogenic (chronic
anxiety and anorexia nervosa), and certain other chronic medical
conditions. In this case, the next step to make a diagnosis is to obtain FSH
which would be expected to be in the low range. You already know that
her prolactin level is normal, which is consistent with the diagnosis.
Prolactin would be elevated with a prolactin-secreting pituitary adenoma.

A. Estrogen level
B. Progesterone level
C. Gonadotropin releasing hormone level (GnRH)
D. Follicle stimulating hormone (FSH)
E. Dehydroepiandrosterone sulfate (DHEAS)
28. A 23-year-old G0 woman with severe dysmenorrhea C. The lesions described are classic for endometriosis. One would
that is unresponsive to non-steroidal anti-inflammatory therefore expect to see endometrial glands/stroma with hemosiderin-
agents and oral contraceptives is taken to the operating laden macrophages. Hyperplastic overgrowth of endometrial
room for a laparoscopy. Blue-black powder burn lesions glands/stroma is consistent with endometrial polyps. Decidual effect on
are seen in the pelvis. A biopsy is performed and sent to the endometrium are seen during pregnancy. Invasion of endometrial
pathology. Which of the following pathologic findings glands into the myometrium is seen with adenomyosis. Well-
would you expect to see in this patient? circumscribed, non-encapsulated myometrium is consistent with myomas.

A. Hyperplastic overgrowth of endometrial

glands/stroma
B. Decidual effect in the endometrium
C. Endometrial glands/stroma and hemosiderin-laden
macrophages
D. Invasion of endometrial glands into the myometrium
E. Well-circumscribed, non-encapsulated myometrium
29. A 24-year-old G0 woman comes into the office because
she has not had her menses for six months. She is in
good health and not taking any medications. She is not
sexually active. She does well in graduate school,
despite her demanding new program. Her height is 5
feet 6 inches and her weight is 104 pounds. Her vital
signs are normal. Her physical examination, including a
pelvic examination, is completely normal. What is the
most likely reason for her amenorrhea?
D. Anorexia nervosa or significant weight loss may cause hypothalamic-
pituitary dysfunction that can result in amenorrhea. A lack of the normal
pulsatile secretion of gonadotropin releasing hormone (GnRH) leads to a
decreased stimulation of the pituitary gland to produce follicle
stimulating hormone (FSH) and luteinizing hormone (LH). This leads to
anovulation and amenorrhea. Although testing for thyroid dysfunction
may be indicated, she has no other symptoms to suggest thyroid disease.
While ovarian dysfunction/failure, premature ovarian failure and
pregnancy cause amenorrhea, they are unlikely in this case.

A. Ovarian dysfunction
B. Thyroid disease
C. Premature ovarian failure
D. Hypothalamic-pituitary dysfunction
E. Pregnancy
30. A 24-year-old G1P1 woman presents with a complaint of
decreasing breast size and hirsutism noted over the last
three months. She also notes her skin feels oily and her
husband has mentioned her voice seems to be getting
deeper. She has no medical or surgical problems and takes
no medications. Physical examination reveals oily skin,
upper lip and chin terminal hair, and normal appearing
breasts. Pelvic examination reveals her clitoris to be 2 cm in
length and 1 cm wide. Which of the following is the most
likely cause of her symptom constellation?
A. The likely cause of this patient's sudden onset of symptom is an
increase in androgens due to a tumor. Hirsutism is often the result of
a benign condition, however, may be a sign of significant disease if
sudden in onset and coupled with virilization. Virilization in the
female may be manifested by frontal hair thinning, oily skin or acne,
deepening of the voice, clitoral enlargement, menstrual irregularities,
and increased muscle strength. Possible causes of virilization include
PCOS, hypothyroidism, androgen producing tumors (ovarian,
adrenal, or pituitary), and anabolic steroid use. A rare cause may be
late onset congenital adrenal hyperplasia.

A. Steroid cell tumor

B. Hypothyroidism
C. Polycystic ovary syndrome
D. Congenital adrenal hyperplasia (early onset)
E. Anabolic steroids
31. A 26-year-old G0 woman comes to the office due to
irregular menses since menarche, worsening for the last six
months. The patient has noted increasing hair growth on her
chin and most recently hair growth on her chest, requiring
that she shave periodically. No one in her family has
hirsutism. On exam, you also notice acne on her chin,
acanthosis nigricans and temporal balding. Her serum
testosterone is elevated. You suspect hyperthecosis. Which
of the following might also be associated with this
condition?
D. Hyperthecosis is a more severe form of polycystic ovarian
syndrome (PCOS). It is associated with virilization due to the high
androstenedione production and testosterone levels. In addition to
temporal balding, other signs of virilization include clitoral
enlargement and deepening of the voice. Hyperthecosis is more
difficult to treat with oral contraceptive therapy. It is also more
challenging to achieve successful ovulation induction.
Hyperthyroidism and hyperparathyroidism are not typically
associated with hyperthecosis. Hyperprolactinemia is typically
associated with amenorrhea and does not cause hirsutism.

A. Hyperthyroidism
B. Hyperprolactinemia
C. Atrophic changes of external genitalia
D. Deepening of the voice
E. Hyperparathyroidism
32. A 26-year-old G0 woman presents with hirsutism and A. Acanthosis nigricans is associated with elevated androgen levels
irregular menses. Her mother, who is diabetic, had similar and hyperinsulinemia. Since this woman has a family history of
complaints prior to menopause. On physical exam, this diabetes and also has acanthosis nigricans, the most appropriate test
patient is noted to have terminal hair on her chin and a of those listed would be the fasting insulin. The other tests would
gray-brown velvety discoloration on the back of her neck. also be reasonable, but hyperinsulinemia is most likely in this patient.
This lesion is acanthosis nigricans. Which of the following is
the most appropriate first test to order for this patient?

A. Fasting insulin
B. TSH
C. 17-hydroxyprogesterone level
D. Cortisol level
E. Pelvic ultrasound
33. A 27-year-old G0 woman comes to the clinic because she has been unable A
to conceive for the last year. She is in good health and has not used any
hormonal contraception in the past. She had normal cycles in the past
every 28 days until about six months ago. At that time, she began to have
irregular menses every two to three months, with some spotting in
between. She is not taking any medications. She has no history of
abnormal Pap smears or sexually transmitted infections. Her physical
examination is normal. Laboratory tests show:

Results Normal Values

Results Normal Values

TSH 10 mIU/ml 0.5-4.0 mIU/ml
Free T4 0.2 ng/dl 0.8-1.8 ng/dl
Prolactin 40 ng/ml <20 ng/ml
FSH 6 mIU/ml 5-25 mIU/ml
LH 4 mIU/ml 5-25 mIU/ml
What is the most appropriate step in the management of this patient?

A. Begin levothyroxine
B. Begin bromocriptine
C. Order a clomiphene citrate ovulation challenge test
D. Obtain a brain MRI
E. Order a thyroid ultrasound
34. A 27-year-old G0 woman presents to the clinic because of concerns that
she has not been able to get pregnant for the last three months. She
married a year ago and was using condoms for contraception, which she
stopped three months ago when she decided to start a family. She is in
good health and her only medication is a prenatal vitamin. Her periods are
regular every 28 days with normal flow; her last period was two weeks
ago. She has no history of sexually transmitted infections and no abnormal
Pap smears. Her husband is also healthy with no medical problems. She is
5 feet 4 inches tall and weighs 130 pounds. Her examination, including a
pelvic exam, is completely normal. What is the most appropriate next step
in the management of this patient?
A. Reassurance and observation is most appropriate
as the patient has only been trying to conceive for
three months. After one month, 20% of couples will
conceive; after three months, 50%; after six months,
75%; and after 12 months, 90% will conceive. Primary
infertility is defined as the inability to conceive for one
year without contraception. The patient is young and
healthy with no obvious reasons for infertility, so at
this point reassurance and observation is the proper
management. There is no reason to order any studies
now, especially since she has normal cycles.

A. Reassurance and observation

B. Hysterosalpingogram
C. Transvaginal pelvic ultrasound
D. Semen analysis
E. Mid-cycle blood LH and FSH levels
35. A 27-year-old G0 woman presents to the clinic because of
concerns that she has not been able to get pregnant for the last
year. She has been married for two years ago and was using birth
control pills for contraception. She stopped using birth control
pills when she decided to start a family one year ago. She is in
good health and her only medication is a prenatal vitamin. Her
periods are regular, every 28 days, with normal flow; her last
period was two weeks ago. She has no history of sexually
transmitted infections and no abnormal Pap smears. Her husband
is also healthy with no medical problems. She is 5 feet 4 inches
tall and weighs 130 pounds. Her examination, including a pelvic
exam, is completely normal. Laboratory results show normal
thyroid function tests and normal prolactin level. What is the most
appropriate next step in the management of this patient?
A. Reassurance and observation
B. Perform a pelvic ultrasound
C. Order a hysterosalpingogram
D. Order a semen analysis
E. Recommend a diagnostic laparoscopy
36. A 27-year-old G0 woman presents to the clinic because of
concerns that she has not been able to get pregnant for the last
year. She has been married for two years and was using oral
contraceptives, which she stopped a year ago to start a family.
She is in good health and her only medication is a prenatal
vitamin. She was hospitalized at age 19 for pelvic inflammatory
disease. Her periods are regular, every 28 days with normal flow;
her last period was two weeks ago. She has no history of
abnormal Pap smears. Her husband is also healthy with no
medical problems. She is 5 feet 4 inches tall and weighs 130
pounds. Her examination, including a pelvic exam, is completely
normal. Which of the following is the most likely diagnostic test to
find out the cause of her infertility?
A. Hysteroscopy
B. Hysterosalpingogram
C. Progesterone level mid-cycle
D. Clomiphene citrate challenge test
E. Cervical mucous monitoring
37. A 27-year-old G1P0 woman complains of mood swings and
fatigue in the week prior to her menstrual period. These
symptoms have worsened over the past six months. Some months
the symptoms are so severe she misses several days of work. Her
medical history is otherwise unremarkable and a physical
examination is normal. Which of the following is the most
appropriate next step in this patient's management?
A. Symptom diary for two months
B. Dietary changes
C. Anxiolytic agent
D. Psychiatric consultation
E. Pelvic ultrasound
D. This patient has primary infertility, since she has not been
able to conceive for one year. She does not appear to have
underlying pathology to explain why she has not conceived,
and her husband's semen has not yet been examined. The male
factor plays a role in about 35% of infertility cases. A pelvic
ultrasound is unlikely to add any information, as the patient has
normal cycles and normal exam. Although a
hysterosalpingogram might be ordered in the future, the male
factor needs to be ruled out first, as it is less invasive to
perform. Even though this patient had been on birth control
pills previously, this should not be affecting her fertility a year
later. In patients who use OCPs for prolonged periods, there
might be a few months delay in returning to normal fertility.
B. This patient is having difficulty conceiving after trying for one
year. Based on her history, the most likely underlying factor is
tubal disease, as she has a history of being hospitalized for a
pelvic infection, most likely pelvic inflammatory disease. This
can cause adhesions and blockage of the tubes, which is best
assessed with a hysterosalpingogram to evaluate the uterine
cavity and tubes. After a single episode of salpingitis, 15% of
patients experience infertility. Hysteroscopy will assess the
uterine cavity and while sometimes used during a work up for
infertility, it does not provide sufficient information about tubal
patency. Progesterone levels, a Clomiphene challenge test or
cervical mucous monitoring are used at times with infertility
workups, but, in a young patient of normal BMI and with
normal cycles, it is unlikely to find major ovulatory dysfunction.
A. Obtaining further history with a menstrual calendar
determines the cyclic nature of the PMS or PMDD symptoms
and helps guide appropriate therapy. While dietary changes
may help, it is first important to establish the diagnosis. An
anxiolytic agent or psychiatric consultation is not indicated.
38. A 28-year-old G0 woman comes to the office for
preconception counseling and the inability to
conceive for one year. She and her husband of
three years are both in good health. She has normal
cycles every 28-33 days. She has intercourse about
once a month, depending on her schedule. She is an
airline pilot and travels a lot. Her examination is
normal. She asks about when to best have
intercourse during her cycle to maximize her
chances of pregnancy. What is the most appropriate
advice to give her?
C. Women are most fertile during the middle of their cycle when they are
ovulating. Assuming normal cycles every 28 days, a woman is most likely to
ovulate on day 14. Since sperm can live for up to three days, intercourse up
to three days before ovulation can still result in pregnancy. Since this patient
has cycles that vary in length, she can best tell when she is ovulating by using
an ovulation predictor kit. The basal body temperature charts tell when a
patient ovulated retrospectively, so it cannot be used to time intercourse to
conceive, as the egg is only viable for about 24 hours. Although having
intercourse more frequently will increase her likelihood of conceiving, it is
not a practical solution for a working person to stop their work in order to
conceive.

A. Keep basal body temperatures and try to attempt

intercourse immediately after the rise in body
temperature
B. Best to attempt intercourse after she is done with
her menses
C. Use ovulation predictor kits and attempt
intercourse after it turns positive
D. Take a leave from her work so she can have
intercourse three times a week until she gets
pregnant
E. Attempt intercourse on day 18 of her cycle
39. A 28-year-old G0 woman presents for an annual C. Amenorrhea associated with exercise falls under the category of
examination. She is in good health and not taking hypothalamic amenorrhea, which causes chronic anovulation. Although it
any medications. She had a history of normal cycles may be related to energy requirements, alterations in the hypothalamic-
until six months ago, when she stopped having pituitary-ovarian axis have been described in athletic women. The patient's
menses after starting an intense exercise regimen. history and physical exam make ovarian failure, androgen excess and
She is 5 feet 6 inches tall and weighs 120 pounds. hyperthyroidism less likely, although a TSH level would still be
Her examination is completely normal. Her urine recommended.
pregnancy test is negative. What is the underlying
pathophysiology of the disease process in this
patient?

A. Psychogenic amenorrhea
B. Premature ovarian failure
C. Hypothalamic amenorrhea
D. Androgen excess
E. Hyperthyroidism
40. A 31-year-old G3P0 woman presents with D. Asherman's syndrome can be caused by curettage or endometritis. The
amenorrhea for six months. She is otherwise in intrauterine synechiae or adhesions result from trauma to the basal layer of
good health and is not taking any medications. She the endometrium, which causes amenorrhea. Chronic endometritis may be
had a miscarriage seven months ago, which was associated with abnormal uterine bleeding and not amenorrhea.
complicated by an infection and required antibiotics Hypothalamic amenorrhea is unlikely because of the temporal relationship of
and a dilation and curettage procedure. Her her amenorrhea to the procedure. Sheehan's syndrome is typically due to
examination is normal. Her laboratory results show severe postpartum hemorrhage leading to pituitary apoplexy.
a Beta-hCG <5 mIU/mL, and normal TSH and
prolactin levels. What is the most likely underlying
cause of this patient's amenorrhea?

A. Chronic endometritis
B. Recurrent miscarriages
C. Hypothalamic-pituitary amenorrhea
D. Asherman's syndrome
E. Sheehan's syndrome
41. A 32-year-old G0 woman comes to the office due to the inability to conceive
for last two years. She reports having been on oral contraceptives for eight
years prior. She had menarche at age 14 and has had irregular cycles about
every three months until she started oral contraceptives, which regulated her
cycles. In the last year, she has had about five cycles in total; her last
menstrual period was six weeks ago. She is otherwise in good health and has
not had any surgeries. She has no history of abnormal Pap smears or
sexually transmitted infections. She is 5 feet 4 inches tall and weighs 165
pounds. On general appearance, she is hirsute on the face and the abdomen.
The rest of her exam is otherwise normal. Which of the following is most
likely to help identify the underlying cause of this woman's infertility?
A. Luteinizing hormone levels
B. Testosterone levels
C. Follicle stimulating hormone levels
D. Thyroid function tests
E. Progesterone levels
42. A 32-year-old G0 woman comes to the office due to the inability to conceive
for the last two years. She reports having been on oral contraceptives for
eight years prior. She had menarche at age 14 and had irregular cycles about
every three months until she started birth control pills, which made her
cycles regular. In the last year, she has had about five cycles in total; her last
menstrual period was six weeks ago. She is otherwise in good health and has
not had any surgeries. She has no history of abnormal Pap smears or
sexually transmitted infections. Her husband of four years is 35-years-old,
and has a 10-year-old son from a previous marriage. She is 5 feet 4 inches
tall and weighs 165 pounds. On general appearance, she is hirsute on the face
and the abdomen. The rest of her exam is otherwise normal. In addition to
weight loss and starting metformin, what is the most appropriate treatment
for this patient's infertility problem?
A. Laparoscopy
B. Ovulation induction agents
C. Intrauterine insemination
D. In vitro fertilization
E. Restart oral contraceptives
43. A 32-year-old G0 woman presents with amenorrhea for the last three
months. She has a long history of irregular cycles, 26 to 45 days apart, for
the last two years. She is otherwise in good health and is not taking any
medications. She is sexually active with her husband and uses condoms for
contraception. She is 5 feet 4 inches tall and weighs 140 pounds. On exam,
she has a slightly enlarged, non-tender uterus. There are no adnexal masses.
Which of the following is the most appropriate test to obtain in this patient?
A. Thyroid stimulating hormone (TSH)
B. Progesterone and estrogen
C. Follicle stimulating hormone (FSH)
D. Urine pregnancy test
E. Pelvic ultrasound
B. This patient most likely has PCOS (polycystic
ovarian syndrome) based on her history of irregular
cycles, her body habitus and hirsutism. Having
normal cycles on the birth control pills (OCPs)
supports the diagnosis as other causes, such as
hypothyroidism, will not normalize the cycles on
OCPs. Testosterone levels will be helpful to
confirm the diagnosis, especially in the presence of
hirsutism. Once a diagnosis is established,
progesterone levels are helpful during medical
treatment to check if the woman is ovulating. An
increased LH/FSH ratio is observed to be elevated
in PCOS patients but each test separately will not
aid in the diagnosis.
B. This patient has PCOS (polycystic ovarian
syndrome) based on her history, signs and
symptoms. It is most important for her to try to lose
weight. Metformin and ovulation induction agents
are the first-line of treatment for ovulatory
dysfunction in PCOS patients. Since there is known
ovulatory dysfunction and there is no reason to
believe there are problems with semen analysis, IVF
is not justified. There is no role for the laparoscopy
in this patient. Although oral contraceptives would
regulate her cycles, it is not indicated because she
is trying to get pregnant.
D. Pregnancy is the most common cause of
amenorrhea. It is important to consider it early in
the workup to avoid unnecessary tests, procedures
and treatments that may be contraindicated during
pregnancy. Although the patient has a history of
irregular cycles and is using condoms for
contraception, it is important to first rule out
pregnancy before initiating further work-up.
44. A 32-year-old G0 woman presents with irregular menses occurring every
six to eight weeks for the past eight months. The bleeding alternates
between light and heavy. Her irregular menses were treated successfully
with medroxyprogesterone acetate (MPA), 10 mg every day, taken for 10
days each month. By which mechanism does the MPA control her periods?
A.Stimulates rapid endometrial growth and regeneration of glandular
stumps
B. Converts endometrium from proliferative to secretory
C. Promotes release of Prostaglandin F2
D. Regenerates functional layer of the endometrium
E. Decreases luteal phase inhibin production
45. A 32-year-old G2P2 woman complains of depression, weight gain and
premenstrual bloating. She has suffered from these symptoms for 18
months and they have not responded to dietary changes and avoidance of
alcohol and caffeine. Her only medications are multivitamins and herbs to
increase her energy. She is very concerned about fatigue that often
interferes with caring for her two children. A prospective symptom diary
completed by the patient indicates mood symptoms, fatigue and bloating
almost every day of the past two months, and regular menstrual cycles
accompanied by breast tenderness. She denies feelings of wanting to hurt
herself or others. Physical examination is unremarkable. Which of the
following conditions is the most likely explanation for this patient's
symptoms?
A. Panic disorder
B. Anxiety disorder
C. Anemia
D. Hypothyroidism
E. Premenstrual dysphoric disorder
46. A 32-year-old G2P2 woman is concerned about symptoms associated with
her menstrual cycle. During the second half of her cycle, she feels anxious,
sad and has difficulty sleeping. She has done research on the Internet and
believes she suffers from premenstrual dysphoric disorder (PMDD). Which
of the following symptoms of the patient is most consistent with this
diagnosis?
A. Cyclic constellation of symptoms during the follicular phase
B. Cyclic occurrence of a minimum of described symptoms and
interference in social functioning
C. Chronic, mild depressive symptoms that have been present for many
years
D. Depressed mood or the loss of interest or pleasure in activities
E. Anxiety/nervousness interfering in social functioning
B. Patients with anovulatory bleeding have
predominantly proliferative endometrium from
unopposed stimulation by estrogen. Progestins inhibit
further endometrial growth, converting the
proliferative to secretory endometrium. Withdrawal of
the progestin then mimics the effect of the involution
of the corpus luteum, creating a normal sloughing of
the endometrium. Stimulation of rapid endometrial
growth, conversion of proliferative to secretory
endometrium, and regeneration of the functional
layer describe effects of estrogen on the
endometrium. Inhibin is increased in the luteal phase.
D. Symptoms of hypothyroidism can mimic typical
symptoms of PMS, but symptoms occur more
constantly throughout the cycle. Diagnosis involves
complete work-up to rule out medical illnesses,
including hypothyroidism. Although fatigue can be
associated with anemia, her presentation is not
consistent with this diagnosis.
B. PMDD is a psychiatric diagnosis, describing a
severe form of premenstrual syndrome in which the
diagnostic criteria include five out of 11 clearly
defined symptoms, functional impairment and
prospective charting of symptoms present during the
last week of the luteal phase that begin to resolve
with the beginning of the follicular phase. All three
areas of symptoms need to be represented for the
diagnosis of PMDD.
47. A 33-year-old G0 woman presents with amenorrhea for
the past 12 months. She also reports a recent onset of
dyspareunia, causing her to feel anxious about having
intercourse. She had menarche at age 15. Her cycles
were normal until two years ago when she began
skipping menses. She is otherwise in good health. She is
5 feet 4 inches tall and weighs 130 pounds. Her physical
examination is completely normal. TSH and prolactin
levels are normal. Urine pregnancy test is negative.
What is the most likely cause of this patient's
amenorrhea?
D. The patient's symptom of dyspareunia is likely caused by vaginal
dryness, which is associated with estrogen deficiency.
Hypergonadotropic amenorrhea is the result of ovarian failure or
follicular resistance to gonadotropin stimulation. The history, physical
exam and labs make the other possibilities less likely: psychogenic
disorder (no chronic anxiety or anorexia nervosa), outflow obstruction
(previously had periods), Asherman's syndrome (no history of pregnancy
or intrauterine procedures), or a pituitary tumor (normal labs).

A. Psychogenic
B. Genital tract outflow obstruction
C. Asherman's syndrome
D. Premature ovarian failure
E. Pituitary adenoma
48. A 34-year-old G2P2 woman presents with concerns of
hormonal changes. She is worried about facial hair
growth, worsening acne, and deepening of her voice.
She also realized that she has missed her period for two
months, and has been sexually active and had tubal
ligation. On examination, she is moderately obese and
noted to have severe acne, upper lip and chin terminal
hair. Her abdomen is obese with moderate hair growth.
Pelvic examination is most notable for an enlarged
clitoris, and pelvic exam reveals an enlarged right-sided
adnexal mass. Which of the following is the most likely
diagnosis in this patient?
A. The most likely diagnosis in this patient is a testosterone-secreting
ovarian tumor. Sertoli-Leydig cell tumors are commonly diagnosed in
women between the ages of 20-40, and are most often unilateral. Rapid
onset of hirsutism and virilizing signs are hallmarks of this disease, and
include many of the findings in this patient including acne, hirsutism,
amenorrhea, clitoral hypertrophy, and deepening of the voice. Abnormal
laboratory findings include suppression of FSH and LH, marked elevation
of testosterone, and presence of an ovarian mass. The constellation of
findings is most consistent with a testosterone-secreting tumor, and a
pelvic ultrasound will confirm the presence of an ovarian mass. The other
tumors do not cause virilization. Granulosa cell tumors and thecomas are
estrogen-secreting tumors.

A. Sertoli-Leydig cell tumors

B. Granulosa cell tumor
C. Benign cystic teratoma
D. Thecoma
E. Cystadenoma
49. A 34-year-old G2P2 woman presents with inter- D. Intermenstrual bleeding is frequently caused by structural
menstrual bleeding for one year. The bleeding typically abnormalities of the endometrial cavity, such as myomas, polyps or
occurs two weeks after her menses and last two to three malignancy. An ultrasound would be helpful as the next step in diagnosis.
days. The symptoms began one year ago and the Although an HSG might reveal structural abnormalities, it is too invasive
bleeding has not changed recently. She is currently as the next step. A colposcopy would not be helpful in the diagnosis, nor
taking oral contraceptives. On pelvic examination, the would obtaining a Prolactin level, as it would be indicated for the
cervix appears normal and the uterus is normal in size evaluation of anovulatory bleeding. Progesterone levels are not helpful
and shape. Her urine pregnancy test is negative; an in a patient on oral contraceptives.
endometrial biopsy is negative for hyperplasia. Which
of the following tests or procedures would be indicated
for further work-up?

A. Prolactin level
B. Progesterone level
C. Hysterosalpingogram (HSG)
D. Pelvic ultrasound
E. Colposcopy
50. A 35-year-old G0 Asian woman presents with irregular menses and
hirsutism of three months duration. The patient has no family history
of hirsutism. On exam, the patient was noted to have terminal hair
growth on her chest and recently had laser treatment to remove
similar hair on her chin. Her total testosterone is 76 ng/dl (normal) and
her DHEAS is 1500g/dl (elevated). Which of the following is the most
likely diagnosis in this patient?
A. Pituitary adenoma
B. Ovarian tumor
C. Cushing's syndrome
D. Adrenal tumor
E. Idiopathic
51. A 35-year-old G0 woman comes to the office because of six months
of spotting between her periods and a desire for a pregnancy. She
reports using 30 pads/cycle the last two months and has blood clots
and cramping pain. Prior menses were light and required 15
pads/cycle. She has been trying to conceive for six months. Her work-
up included a transvaginal ultrasound which revealed a 2 cm
endometrial polyp. What is the next best step in the management of
this patient?
A. Hysteroscopic polypectomy
B. Observation
C. Combination birth control pills
D. Endometrial ablation
E. In-vitro fertilization
52. A 35-year-old G0 woman presents with irregular menstrual periods
occurring every six to twelve weeks with occasional inter-menstrual
bleeding. Currently, she has been bleeding daily for the last four
weeks. She reports that her periods have always been irregular, but
have become more so with heavier flow and cramping in the last year.
She is sexually active with one partner. On physical exam, she is
morbidly obese with no abnormalities detected on pelvic exam. Which
of the following is the most appropriate next step in the management
of this patient?
A. Luteinizing hormone level (LH)
B. Follicle stimulating hormone level (FSH)
C. Testosterone level
D. Pelvic CT
E. Endometrial biopsy
D. The short duration of symptoms and the significantly
elevated DHEAS support the diagnosis of an adrenal
tumor as the etiology of the patient's symptoms. In
addition, the patient is Asian and is less likely to have a
predisposition to idiopathic hirsutism. Asians with
polycystic ovarian syndrome are less likely to present with
overt hirsutism than other ethnic groups.
A. Management of an endometrial polyp includes the
following: observation, medical management with
progestin, curettage, surgical removal (polypectomy) via
hysteroscopy, and hysterectomy. Observation is not
recommended if the polyp is > 1.5 cm. In women with
infertility polypectomy is the treatment of choice. While
her inability to get pregnant may be more complicated
than just her polyp, removal of the polyp should occur
prior to infertility treatments.
E. Endometrial biopsy should be performed to rule out
endometrial hyperplasia or carcinoma given the history of
irregular bleeding, coupled with the increased risk of
these diagnoses in morbidly obese patients. While an
ultrasound may be helpful, a pelvic CT is not useful in the
workup for potential endometrial neoplasia. LH and FSH
levels would not aid in the diagnostic workup and
testosterone levels would not be useful, unless signs of
hirsutism or virilization are present.
53. A 35-year-old G2P2 woman comes to the office due to heavy menstrual
periods. The heavy periods started three years ago and have gradually
worsened in amount of flow and duration. The periods are now interfering
with her daily activities. The patient had two spontaneous vaginal
deliveries. She smokes one pack of cigarettes per day. On pelvic
examination, the cervix appears normal and the uterus is normal in size,
without adnexal masses or tenderness. A urine pregnancy test is
negative. TSH and prolactin levels are normal. Hemoglobin is 12.5 mg/dl.
On pelvic ultrasound, a 2 cm submucosal leiomyoma is noted. An
endometrial biopsy is consistent with a secretory endometrium; no
neoplasia is found. Which of the following would be the best therapeutic
option for this patient if she desires to have another child?
A. Hysteroscopy with myoma resection
B. Laparoscopic myomectomy
C. Endometrial ablation
D. Oral contraceptives
E. Dilation and curettage
54. A 36-year-old G0 woman presents due to increasing facial hair growth
and irregular menstrual cycles. She has gained 40 pounds over the last
three years. Her symptoms began three years ago and have gradually
worsened. She has never been pregnant and is not currently on any
medications. On physical exam, she is overweight with dark hair growth at
the sideburns and upper lip. The pelvic exam is normal. Which of the
following would you expect to find in this patient?
A. Decreased luteinizing hormone levels
B. Elevated free testosterone
C. Decreased prolactin level
D. Increased ovarian estrogen production
E. Elevated 17-hydroxyprogesterone
55. A 36-year-old G1P1 woman comes to the office due to hair loss. She
delivered a healthy infant girl three months ago. She is currently on a
progestin-only oral contraceptive pill since she is breastfeeding. In the
last month, she has noticed a large amount of hair on her brush each
morning. Her father has male pattern baldness and her mother, who is
postmenopausal, has had some thinning of her hair, as well. Testosterone
and TSH levels are within the normal range. Which of the following is the
most likely underlying cause for alopecia in this patient?
A. Genetic predisposition
B. Progesterone only pills
C. High estrogen levels during pregnancy
D. Stress during pregnancy and delivery
E. Breastfeeding
A. Hysteroscopic myomectomy preserves the uterus,
while removing the pathology causing the patient's
symptoms. A laparoscopic approach is not indicated as
the myoma is submucosal and not accessible using a
laparoscopic approach. Endometrial ablation destroys
the endometrium and can create Asherman's
syndrome, thus it is reserved for patients who have
completed childbearing. Dilation and curettage is
unlikely to remove the myoma and is a blind procedure
(carried out without direct visualization). Oral
contraceptives would typically help with heavy menses,
but are contraindicated in this patient, who is over 35
and smokes.
B. This patient likely has polycystic ovarian syndrome
(PCOS). PCOS patients have testosterone levels at the
upper limits of normal or slightly increased. Free
testosterone (biologically active) is elevated often
because sex hormone binding globulin is decreased by
elevated androgens. LH is increased in response to
increased circulating estrogens fed by an elevation of
ovarian androgen production. Insulin resistance and
chronic anovulation are hallmarks of PCOS. Prolactin
levels may be elevated in amenorrhea but are not
elevated in patients with PCOS.
C. Postpartum telogen effluvium (hair loss) affects 40-
50% of women postpartum. High estrogen levels in
pregnancy increase the synchrony of hair growth.
Therefore, hair grows in the same phase and is shed at
the same time. Occasionally, this can result in significant
postpartum hair loss at 1 to 5 months postpartum with 3
months after delivery being most common time. In the
non-pregnant state, asynchronous hair growth occurs
such that a portion of hair is in one of the three hair
growth cycles at all times. While genetic predisposition
and stress can be causes of hair loss, they are unlikely
explanation in this post partum woman.
56. A 37-year-old G0 woman complains that she experiences mood swings, A. Exercise increases circulating endorphins in the brain
irritability, bloating and headaches monthly for two to three days prior which are "feel good" hormones and act similar to
to her menstrual cycle. Her medical history is unremarkable and serotonin. Therefore, in addition to being a benefit to
physical examination is normal. The physician advises her to keep a cardiovascular health, regular exercise can significantly
calendar of her symptoms. He also recommends a balanced diet, decrease symptoms of PMS.
avoidance of caffeine and alcohol, and daily regular exercise. The
patient has never exercised regularly and wonders how this will help her
mood swings and bloating. Which of the following would provide the
best explanation for the benefits of exercise on her PMS symptoms?

A. Endorphins
B. Cortisol
C. Progesterone
D. Estrogen
E. Androgen
57. A 37-year-old G1P1 woman has experienced symptoms of depression D. Selective serotonin reuptake inhibitors increase the
and difficulty concentrating the week prior to her menstrual period for amount of active serotonin in the brain and have been
the last three years, since her tubal ligation. She kept a symptom diary found to be effective in alleviating PMS and PMDD
for three months revealing symptoms clustered around her menstrual symptoms. Patients can take the medication either every
cycle. She was diagnosed with premenstrual syndrome and began a day or for 10 days during the luteal phase. Progesterone
regular exercise routine with dietary modifications, but only noticed mild cream will not help her symptoms. Herbal therapies
relief in her symptoms. Work-up is otherwise unremarkable. Which of the such as evening primrose oil and ginkgo have not been
following will most likely alleviate her symptoms? shown to improve PMDD symptoms. Symptoms due to
hypothyroidism would be present throughout her cycle.
A. Evening primrose oil
B. Ginkgo
C. Progesterone cream
D. Fluoxetine hydrochloride
E. Levothyroxine sodium
58. A 37-year-old G1P1 woman suffers from severe mood swings the week D. Vitamin deficiency of A, E and B6 have been
before her menstrual cycle. The mood swings resolve after she stops associated with an increase in PMS. Replacement of
bleeding. You diagnose her with premenstrual syndrome (PMS) after these vitamins might improve PMS symptoms and avoid
obtaining further history and a normal examination. In addition to further medical therapy.
exercise, which of the following might be suggested to help decrease
this patient's symptoms?

A. Folic acid
B. Ginkgo
C. Fish oil
D. Vitamin B6
E. Potassium
59. A 37-year-old G2P1011 woman comes to the clinic with her
husband due to the inability to conceive for the last year. She
reports being in good health and not having problems with her
prior pregnancy two years ago, except for some postpartum
depression for which she was placed on imipramine and which
she continues to take. She took birth control pills after her
pregnancy and stopped one year ago, when she began trying
to conceive. Her periods were regular on the pills, but have
been irregular since she stopped taking them. She has no
history of sexually transmitted infections or abnormal Pap
smears. Her husband is also healthy and he fathered their first
child. Her physical examination is completely normal.
Laboratory tests show:
C. This patient has hyperprolactinemia due to imipramine. The
patient has to be weaned off imipramine (instead of abrupt
discontinuation to minimize withdrawal symptoms) and placed on
a more appropriate medication. Once she is off imipramine and
the cause of her elevated prolactin levels is confirmed, her normal
menses should resume. Although MRI of the brain would be a
reasonable step, it would be premature, and visual field
examination does not aid in the diagnostic work-up. It would be
premature to obtain an MRI or begin bromocriptine without this
intermediate step. An endometrial biopsy is not indicated at this
point, especially since the patient had normal cycles on OCPs.
Although Clomid is used to help with ovulatory dysfunction, the
hyperprolactinemia must be addressed first.

Results Normal Values

TSH 2.1 mIU/ml 0.5-4.0 mIU/ml
Free T4 1.1 ng/dl 0.8-1.8 ng/dl
Prolactin 60 ng/ml <20 ng/ml
FSH 6 mIU/ml 5-25 mIU/ml
LH 4 mIU/ml 5-25 mIU/ml

What is the most appropriate next step in the management of

this patient's subfertility?

A. Begin bromocriptine
B. Ovulation induction with clomiphene citrate (Clomid)
C. Wean off imipramine
D. Perform a visual field examination
E. Obtain a brain MRI
60. A 37-year-old G3P3 woman complains of severe premenstrual
symptoms for the past two years. She finds her mood swings
and irritability troubling and requests a hysterectomy, as she
thinks that this procedure will alleviate her symptoms. Past
medical history is only remarkable for high cholesterol and
her physical examination, including pelvic examination, is
normal. The patient's physician does not recommend a
hysterectomy. Which of the following is the most likely
explanation for the physician's recommendation not to
perform a hysterectomy in this patient?
E. The patient's mood swings are influenced by the hormonal shifts
controlled by the hypothalamic-pituitary-ovarian axis. A
hysterectomy or endometrial ablation would only resolve the
menstrual bleeding component of this patient's symptoms, and
have no effect on the hormonal production of the ovaries.
Removal of her ovaries may improve her symptoms but would
increase her risk for future problems, including osteoporosis and
menopausal symptoms. A bilateral oophorectomy would be the
last option for this patient as many medical options are available
to treat her symptoms.

A. An endometrial ablation would be preferable

B. Past medical history
C. Influence of thyroid hormone on symptoms
D. Influence of adrenal gland on symptoms
E. Influence of ovaries on symptoms
61. A 41-year-old G2P2 woman presents with menstrual pain,
menorrhagia, irregular periods and intermenstrual bleeding. She
describes the pain as pressure and cramps. Ibuprofen improves
the pain, but does not entirely eliminate the discomfort. Pelvic
examination reveals a 14-week size uterus with irregular masses
within the uterus. Pelvic ultrasound confirms the diagnosis of
fibroids. What is the most appropriate next step in the
management of this patient?
A. CA125 assay
B. CT scan of the pelvis
C. Endometrial biopsy
D. GnRH agonist
E. Hysterectomy
62. A 41-year-old G3P3 woman reports heavy menstrual periods
occurring every 26 days lasting eight days. The periods have been
increasingly heavy over the last three months. She reports soaking
through pads and tampons every two hours. She has a history of
three uncomplicated spontaneous vaginal deliveries and a tubal
ligation following the birth of her last child. On pelvic examination,
the cervix appears normal and the uterus is normal in size. Which
of the following tests or procedures would be most useful in
further evaluation of this patient's complaint?
A. Follicle stimulating hormone level
B. Prolactin level
C. Coagulation studies
D. Pelvic ultrasound
E. Hysteroscopy
63. A 42-year-old G0 woman presents to the office for a health
maintenance examination. She reports that her menses have been
irregular her entire life ever since menarche at age 15, occurring
every 20-45 days. She is not sexually active and reports no other
medical problems. She smoked for two years during her
adolescence. She has a family history of cervical cancer affecting
her mother at age 42. On examination, she is 5 feet 4 inches tall
and weighs 180 pounds (BMI 31). She has noticeable hair growth on
her upper lip and chin. The rest of her examination including a
pelvic examination is normal. Compared to the general
population, which of the following malignancies is she at
increased risk for developing?
A. Breast
B. Endometrial
C. Cervical
D. Lung
E. Colorectal
C. This patient has classic symptoms of leiomyomata, including
menorrhagia. An endometrial biopsy should be performed on
all women over age 40 with irregular bleeding to rule out
endometrial carcinoma. The CA125 assay measures the level of
CA125 in the blood and is increased in some types of cancer,
including ovarian cancer or other conditions. This non-specific
marker is not indicated in this patient. A CT scan of the pelvis is
also not indicated. A simple pelvic ultrasound could be used
to help confirm the clinical diagnosis. GnRH agonist and
hysterectomy are not used until the diagnosis of leiomyomata
uteri is confirmed. Her desire for future fertility should be
discussed.
D. A pelvic ultrasound would image the endometrium and
assess for endometrial pathology such as polyps or
submucosal fibroids. In the absence of menopausal symptoms,
FSH is unlikely to be helpful. The patient is unlikely to have a
coagulation disorder, as she has had three spontaneous
vaginal deliveries without postpartum hemorrhage.
Hysteroscopy is more invasive than an ultrasound as a first
step and would not be helpful if the cause of abnormal
bleeding is myometrial pathology such as intramural and
subserosal fibroids or adenomyosis. Hyperprolactinemia is
found with prolactin-secreting adenomas associated with
amenorrhea.
B. This patient most likely has polycystic ovarian syndrome
(PCOS), with her clinical manifestation of oligo-menorrhea,
obesity, and hirsutism. Because of the chronic unopposed
estrogen exposure that accompanies women with PCOS,
these individuals carry a higher risk of developing endometrial
hyperplasia and cancer. Although obesity in postmenopausal
women is associated with a higher risk of breast cancer, it
does not increase the risk in premenopausal women. PCOS is
considered to increase the risk of ovarian cancer. She does
not have obvious risk factors for cervical cancer, lung, or
colon cancer, but should be screened and counseled
accordingly based on usual guidelines.
64. A 42-year-old G2P2 woman complains of
bloating, mood swings and irritability the week
prior to her menses. She is convinced that
something is wrong with her hormone levels. In
addition to a complete physical examination,
which of the following diagnostic tools would
provide information to accurately determine the
diagnosis?
D. A calendar of symptoms can clarify if there is a cyclic or constant nature of
the symptoms. Often women will mistakenly attribute their symptoms to their
menstrual cycle. Different self-reporting scales have been written to assist
patients track their symptoms. Because she is menstruating regularly, there is no
role for obtaining serum hormone levels.

A. Pelvic ultrasound
B. Estradiol level
C. CAGE questionnaire
D. Prospective symptom calendar
E. Mini mental status examination
65. A 42-year-old G2P2 woman undergoes a E. Well-circumscribed, non-encapsulated myometrium confirms the diagnosis of
hysterectomy for definitive treatment of her fibroids. Hyperplastic overgrowth of endometrial glands/stroma is consistent
dysmenorrhea and large uterine fibroids. The with endometrial polyps. Decidual effect on the endometrium are seen during
uterus is sent to pathology. Which of the pregnancy. Invasion of endometrial glands into the myometrium is seen with
following would confirm the diagnosis of adenomyosis.
fibroids?

A. Hyperplastic overgrowth of endometrial

glands/stroma
B. Decidual effect in the endometrium
C. Endometrial glands/stroma and hemosiderin-
laden macrophages
D. Invasion of endometrial glands into the
myometrium
E. Well-circumscribed, non-encapsulated
myometrium
66. A 42-year-old G4P4 woman presents for D. Hysterectomy is nearly 80% effective in eliminating pain and abnormal
management of suspected adenomyosis. She bleeding, if she is willing to undergo surgery. Gonadotropin releasing agents are
had a tubal ligation four years ago. A pelvic the first choice for medical therapy for the pain, but the problem is that the
examination shows an enlarged, soft, boggy adenomyosis seems to recur after discontinuing the therapy. Endometrial
uterus. A pregnancy test is negative and she is ablation and insertion of a levonorgestrel-containing intrauterine system are
mildly anemic. An ultrasound shows an enlarged options in women who decline hysterectomy or desire to maintain fertility. For
uterus with no fibroids. The patient desires abnormal bleeding problems and desire for uterine conservation, a
definitive treatment for this condition. What is progesterone intrauterine contraceptive device can also be used to improve
the most appropriate next step in her irregular bleeding. Hysteroscopic endometrial ablation can be a treatment for
management? adenomyosis.

A. Continuous estrogen/progestin therapy

B. Endometrial ablation
C. GnRH agonist
D. Hysterectomy
E. Insertion of a levonorgestrel containing
intrauterine system
67. A 42-year-old G4P4 woman presents with a history of
progressively worsening severe menstrual pain. Menses are
regular, but she complains of very heavy flow requiring both a
menstrual pad and tampon and often bleeds through both. She
takes oxycodone that her husband used for back pain to relieve
her dysmenorrhea. She had a tubal ligation four years ago.
Pelvic examination shows an enlarged, soft, boggy uterus. No
masses are palpated. Pregnancy test is negative, hemoglobin 9.8
and hematocrit 28.3%. What is the most likely diagnosis?
A. Adenomyosis
B. Endometrial carcinoma
C. Endometriosis
D. Primary dysmenorrhea
E. Endometrial hyperplasia
68. A 45-year-old G2P2 woman comes to the office because of
heavy and irregular menstrual periods. The heavy periods
started three years ago and have gradually worsened in amount
of flow over time. The periods are interfering with her daily
activities. The patient has had two spontaneous vaginal
deliveries, followed by a tubal ligation three years ago. On
pelvic examination, the cervix appears normal and the uterus is
normal in size without adnexal masses or tenderness. A urine
pregnancy test is negative. TSH and prolactin levels are normal.
Hemoglobin is 12.5 mg/dl. On pelvic ultrasound, she has a
normal size uterus and a 2 cm simple cyst on the right ovary.
Endometrial biopsy is consistent with a secretory endometrium;
no neoplasia is found. What is the most likely diagnosis in this
patient?
A. Polycystic ovarian syndrome
B. Mid-cycle bleeding
C. Abnormal uterine bleeding
D. Benign cystic teratoma
E. Ovarian cancer
A. This is a typical presentation of adenomyosis (presence of
endometrial glands and supporting tissues in the muscle of the
uterus). The gland tissue grows during the menstrual cycle and,
at menses, tries to slough, but cannot escape the uterine muscle
and flow out of the cervix as part of normal menses. This
trapping of the blood and tissue causes uterine pain in the form
of monthly menstrual cramps. Endometrial hyperplasia and
carcinoma are less likely in a woman with regular menses and no
inter-menstrual spotting. Endometriosis would most likely have
presented earlier in life and would not explain the enlarged
uterus.
C. Abnormal uterine bleeding is a term used to describe uterine
bleeding abnormalities. This term can encompass both structural
causes (polyp, adenomyosis. Leiomyoma, or malignancy [or
hyperplasia]) as well as non-structural causes (coagulopathies,
ovulatory dysfunction, endometrial, iatrogenic or not classified).
The acronym PALM-COEIN is a means for this classification. This
patient had a complete workup, including TSH, Prolactin, pelvic
ultrasound and endometrial biopsy, which were all normal. Mid-
cycle bleeding at the time of ovulation is due to the drop in
estrogen. Ovarian teratomas are not associated with abnormal
menses. They typically present with abdominal or pelvic pain
which may be associated with torsion. The 2 cm cyst is a
functional cyst and is a common finding in ovulatory patients.
69. A 45-year-old G3P3 woman comes to the office
because she has been unable to conceive for the last
two years. She is healthy and has three children, ages
10, 12 and 14, whom she conceived with her husband.
She used a copper IUD after the birth of her last child
and had it removed two years ago, hoping to have
another child. She has no history of sexually
transmitted infections or abnormal Pap smears. Her
cycles are regular every 28 to 32 days. She is not
taking any medications. She has been married for the
last 16 years, and her husband is 52-years-old and in
good health. Her physical examination, including a
pelvic exam, is completely normal. Which of the
following is the most appropriate next step in the
management of this patient?
A. Hysteroscopy
B. Hysterosalpingogram
C. Clomiphene challenge test
D. Sperm penetration assay
E. Basal body temperatures for six months
70. A 48-year-old G2P2 woman comes to your office
because she has skipped her menstrual period for the
past three months. She denies any menopausal
symptoms. Review of symptoms and physical exam are
unremarkable. What is the most likely diagnosis in this
patient?
A. Hypothyroidism
B. Early pregnancy
C. Perimenopause
D. Premature ovarian failure
E. Autoimmune disorder
71. A 49-year-old G1P1 woman comes to your office for
menopause counseling. She has been experiencing
severe sleep disturbances and night sweats for the
past four months. She would like to begin hormone
therapy, but is concerned because she has elevated
cholesterol levels for which she takes medication. You
explain to her that hormone therapy has the following
effect on a lipid/cholesterol profile:
A. Both HDL and LDL levels increase
B. Both HDL and LDL levels decrease
C. HDL and LDL levels are unaffected
D. HDL levels increase and LDL levels are unaffected
E. HDL levels increase and LDL levels decrease
C. This patient, most likely, has decreased ovarian reserve due to her age.
A clomiphene challenge test, which consists of giving clomiphene citrate
days five to nine of the menstrual cycle and checking FSH levels on day
three and day 10, will help determine ovarian reserve. This will help counsel
the patient on appropriate options to have a child, as most women will not
be able to conceive at this age and would not be good candidates for
ovarian stimulation or IVF. Even though this patient had an IUD in the past,
there is no reason to believe that this contributed to her inability to
conceive, as IUDs do not cause infertility and she has no risk factors for
tubal disease. Having her keep basal body temperatures for six months
would be a waste of time for this patient, who is already 45. A semen
analysis or sperm penetration assay is not necessary as a first step as she
was able to conceive from her husband previously without problems. Most
likely this patient will have to use a donor egg if she wants to carry the
pregnancy herself.
C. Although there has been a decline in the average age of menarche with
the improvement in health and living conditions, the average age of
menopause has remained stable. The Massachusetts Women's Health Study
reports that the average age of menopause is 51.3. This patient is most
likely perimenopausal and will probably have more menstrual periods in
the future. Although it is important to consider pregnancy and
hypothyroidism, this patient's presentation is most consistent with
perimenopause. Premature ovarian failure occurs before age 35.
E. Recent data have confirmed the overall positive effects of hormone
therapy on serum lipid profiles. The most important lipid effects of
postmenopausal hormone treatment are the reduction in LDL cholesterol
and the increase in HDL cholesterol. Estrogen increases triglycerides and
increases LDL catabolism, as well as lipoprotein receptor numbers and
activity, therefore causing decreased LDL levels. Hormones inhibit hepatic
lipase activity, which prevents conversion of HDL2 to HDL3, thus increasing
HDL levels. Hormone therapy is not currently recommended for the
primary prevention of heart disease.
72. A 49-year-old G2P2 woman status post hysterectomy at age 45 for
fibroids presents to your office complaining of severe vasomotor
symptoms for three months. Hot flashes are affecting her quality of
life and she would like to discuss options for treatment. What
treatment option for hot flashes associated with menopause do you
recommend as the most effective?
A. Lifestyle modifications such as dressing in layers
B. Estrogen
C. Selective estrogen receptor modulator (SERMs)
D. Selective serotonin reuptake inhibitors (SSRIs)
E. Treatment with phytoestrogen (soy)
73. A 51-year-old G1P1 woman presents for annual examination. She
notes vaginal dryness, some hot flashes, and fatigue. She reports that
her last menstrual period was 14 months ago. She and her husband
use lubrication for intercourse, and she denies any significant pain.
Her past medical history is significant for hypertension, which she
controls with diet and regular exercise. She is concerned that she
should begin hormone replacement, because her mother started HRT
around the same age. Which of the following is the most appropriate
next step in her management?
A. Expectant management
B. FSH level
C. LH level
D. Estrogen level
E. Initiate combination HRT
74. A 53-year-old G2P2 woman comes to your office complaining of six
months of worsening hot flashes, vaginal dryness, night sweats, and
sleep disturbances. Her last normal menstrual period was six months
ago and she has been experiencing intermittent small amounts of
vaginal bleeding. Her medical history is significant for hypertension,
which is well-controlled by a calcium-channel blocker, type 2
diabetes, for which she takes metformin, and hyperthyroidism, for
which she takes propylthiouracil. The patient is 5 feet 7 inches tall
and weighs 140 pounds. Blood pressure is 120/70. Physical
examination is unremarkable. Which of the following medical
conditions in this patient is a contraindication to treatment of
menopausal symptoms with hormone therapy?
A. Vaginal bleeding
B. Hypertension
C. Diabetes
D. Osteoporosis
E. Hyperthyroidism
B. Except for estrogen receptor modulator therapy, all of
the above treatment options will improve hot flash
symptoms. Treatment with estrogen is most effective, and
the current recommendation is for the lowest dose for the
shortest duration of time. Hot flashes will resolve
completely in 90% of patients receiving this therapy.
Raloxifene, a selective estrogen receptor modulator, may
actually cause hot flashes to worsen in a patient who has
not stopped having these symptoms completely. SSRI
antidepressants, some anti-seizure medications and
alternative treatments, such as soy products and herbs,
have not been shown to be as effective as estrogen.
A. Expectant management is reasonable in this patient, as
she notes minimal menopausal symptoms. Her vaginal
dryness is not interfering with her ability to enjoy
intercourse, and she has only occasional hot flashes. An
FSH level is not indicated as by definition she is menopausal
given amenorrhea for greater than 12 months. Estrogen and
LH levels are not indicated in the diagnosis of menopause.
While HRT is appropriate for patients with significant
menopausal symptoms, and should be used at the lowest
effective dose for the shortest amount of time, this patient
at this time is not experiencing significant symptoms and
therefore HRT should not be initiated at this time.
A. The principal symptom of endometrial cancer is
abnormal vaginal bleeding. Although the patient's
worsening symptoms make treatment an important
consideration, the specific organic cause(s) of abnormal
bleeding must be ruled out prior to initiating therapy. A
tissue diagnosis consistent with normal endometrium or a
pelvic ultrasound with an endometrial stripe of <4 mm
ought to be documented. In addition, risks and benefits of
hormone replacement therapy must be discussed with this
patient at length prior to beginning treatment.
75. A 54-year-old G2P2 woman presents to your office for
a health maintenance examination. Her last menstrual
period was eight months ago. She complains of severe
vasomotor symptoms, vaginal dryness, and
dyspareunia, and desires treatment for her symptoms.
She has otherwise been in good health and has no
significant past medical or surgical history. Her family
history is significant for a mother who has severe
osteoporosis at the age of 75, a grandmother who died
of breast cancer at the age of 79, and a father who died
at age 77 from a myocardial infarction. She denies
smoking, alcohol or drug use. On physical exam her BP
is 130/78, pulse is 84, and BMI is 26. The remainder of
her exam is within normal limits except for severe
vaginal atrophy noted on the pelvic examination. The
best recommendation for this patient would include
which of the following?
A. Lowest effective dose of combination hormone
replacement therapy for the shortest duration possible
B. Long term hormone replacement therapy to treat her
vasomotor symptoms and prevention of osteoporosis
C. Testosterone cream
D. Progesterone cream
E. Biosphophonates
76. A 54-year-old G4P4 woman who has been menopausal
for four years recently underwent a total vaginal
hysterectomy and bilateral salpingo-oophorectomy for
vaginal prolapse. She comes in for a postoperative
check up and complains of hot flashes and wonders
why she is experiencing menopause again. Which of the
following most likely explains why she is experiencing
these symptoms?
A. Increased postoperative liver metabolism
B. Decreased adrenal estrogen production
C. Removal of an occult estrogen-producing tumor
D. Decreased circulating androgens
E. Cessation of ovarian estrogen production
A. The American College of Obstetricians and Gynecologists (ACOG)
recommendations on hormone replacement therapy considers hormone
replacement therapy (HRT) the most effective treatment for severe
menopausal symptoms that include hot flashes, night sweats and vaginal
dryness. The physician should counsel the woman about the risks and
benefits before initiating treatment. ACOG recommends "the smallest
effective dose for the shortest possible time and annual reviews of the
decision to take hormones." HRT should not be used to prevent
cardiovascular disease due to the slight increase in risk of breast cancer,
myocardial infarction, cerebrovascular accident, and thromoboembolic
events. A woman with an intact uterus should not use estrogen-only
therapy because of the increased risk of endometrial cancer. In addition
to the same risks as FDA approved treatments, bioidentical hormones
such as testosterone and progesterone cream may have additional
associated risks. While her family history is significant for one second
degree relative with breast cancer, this is not an absolute
contraindication for short-term HRT.
D. Estrogen production by the ovaries does not continue beyond
menopause. However, estrogen levels in postmenopausal women can be
significant due to the extraglandular conversion of androstenedione and
testosterone to estrogen. This conversion occurs in peripheral fat cells
and, thus, body weight has been directly correlated with circulating levels
of estrone and estradiol. Since menopausal ovaries are known to
continue production of androgens, surgical removal of postmenopausal
ovaries may result in the resurgence of menopausal symptoms from the
abrupt drop in circulating androgens.
77. A 58-year-old G3P1 woman presents to your office for her a
health maintenance examination. She became menopausal
at age 54. Her past medical history is significant for angina.
She experienced a hip fracture 14 months ago when she
tripped and fell while running after her grandson. She has
not had any surgeries. She takes no medications and has no
known drug allergies. She smokes 10 cigarettes a day and
drinks a glass of red wine at dinner. Her father was
diagnosed with colon cancer at the age of 72. Physical exam
revealed a blood pressure of 120/68, pulse of 64, and BMI of
22. Her heart, lung, breast and abdominal exams were
normal. Pelvic exam was consistent with vaginal atrophy and
a small uterus. There was no adnexal tenderness and no
masses were palpated. In addition to obtaining a bone
mineral density scan, what is the next step in the
management plan for this patient?
A. Repeat bone mineral density in one year
B. Repeat bone mineral density at age 65
C. Begin hormone replacement therapy
D. Begin treatment with bisphosphonates
E. Test for the presence of biochemical bone markers in the
blood
78. A 58-year-old G3P3 woman has been postmenopausal for
five years and is concerned about osteoporosis. She has
declined hormone therapy in the past. Her mother has a
history of a hip fracture at age 82. A physical exam is
unremarkable. In addition to weight bearing exercise and
vitamin D supplementation, what optimal daily calcium
intake should she take?
A. None
B. 400 mg
C. 800 mg
D. 1200 mg
E. 1600 mg
79. A 58-year-old G3P3 woman who has been menopausal since
age 50 comes to you for a health maintenance examination.
She is in good health, eats a balanced diet, exercises
regularly, and has an unremarkable physical exam. Her bone
mineral density as determined by central dual energy X-ray
absorptiometry is -1.7. She wants to discuss treatment for her
osteopenia. What is the next step in the management of this
patient?
A. Evaluate her risk factors for fracture
B. Determine her frequency of exercise
C. Assess her exogenous dietary intake of estrogen
D. Assess her exogenous dietary intake of progesterone
E. Repeat DEXA scan in one year
D. This patient has many of the major risk factors for osteoporosis
including history of fracture as an adult, low body weight and being
a current smoker. Patients who already have had an osteoporotic
fracture may be treated on this basis alone. Prior to beginning
treatment with bisphosphonates, a bone mineral density (BMD)
should be documented and repeated at two-year intervals to
monitor treatment. DEXA is the test of choice for measuring BMD. A
nuclear medicine bone scan may be useful to rule out a pathologic
fracture from metastatic disease. General recommendations for the
prevention of osteoporosis include eating a balanced diet that
includes adequate intake of calcium and vitamin D, regular physical
activity, avoidance of heavy alcohol consumption, and smoking
cessation. Bone markers are used in research but are not yet a
reliable predictor of BMD. Hormone replacement therapy is not
recommended long term for disease prevention especially in
patients with cardiovascular disease.
D. Calcium absorption decreases with age because of a decrease in
biologically active vitamin D. A positive calcium balance is necessary
to prevent osteoporosis. Calcium supplementation reduces bone
loss and decreases fractures in individuals with low dietary intakes. In
order to remain in zero calcium balance, postmenopausal women
require a total of 1200 mg of elemental calcium per day.
A. The World Health Organization (WHO) defines osteopenia (low
bone mass) as -1 to -2.5. The American College of Obstetricians and
Gynecologists (ACOG) Committee Opinion recommends that
physicians interpret T scores between 1.0 and 2.5 in combination
with the patient's risk factors for fracture. The authors state:
"Clinicians must be careful because the diagnosis of osteopenia
often is interpreted as indicating a pathologic skeletal condition or
significant bone loss, neither of which is necessarily true. Until better
models of absolute fracture risk exist, postmenopausal women in
their 50s with T scores in the osteopenia range and without risk
factors may well benefit from counseling on calcium and vitamin D
intake and risk factor reduction to delay initiation of pharmacologic
intervention." Some of the risk factors for fracture include prior
fracture, family history of osteoporosis, race, dementia, history of
falls, poor nutrition, smoking, low body mass index, estrogen
deficiency, alcoholism, and insufficient physical activity.
80. A mother brings her 16-year-old daughter to
the doctor because she has not begun menses.
She performs poorly in school because of
dyslexia. On physical examination, she is 4 feet
11 inches tall, 100 pounds and has Tanner stage
I breast and pubic hair growth. Her chest is
broad, breast nipples are widely spaced and
her neck is thickened. No genital tract
abnormalities are noted on exam. Which of the
following is the most likely cause of her
delayed sexual maturation?
A. Partial deletion of the long arm of the X
chromosome
B. Down Syndrome
C. Noonan Syndrome
D. Turner Syndrome
E. Rokitansky-Kuster-Hauser Syndrome
D. The genetic defect of Turner syndrome is the absence of one of the X
chromosomes. These females have failure to establish secondary sexual
characteristics, short stature and characteristic physical features: pterygium colli,
shield chest and cubitus valgus. Partial deletions of the long arm of the X
chromosome also cause premature ovarian failure. The average age of puberty in
females with Down syndrome is not significantly different than normal females.
Clinically, patients with Noonan syndrome typically have normal puberty and
fertility. They may have short stature, webbed neck, heart defects, and abnormal
faces. Individuals with Noonan syndrome have a normal karyotype. Rokitansky-
Kuster-Hauser Syndrome causes vaginal and uterine agenesis and is not suspected
in this case due to the normal pelvic exam findings.
 Unit 5: Neoplasia
Study online at quizlet.com/_2is583

1. A 17-year-old G0 female presents with vaginal spotting C. In the face of discrepancy between dates and uterine size, a pelvic
for the last three days. Her last menstrual period was six ultrasound is indicated to confirm dates, exclude multiple gestation,
weeks ago. Vitals signs are normal. Abdominal and pelvic uterine abnormalities, and molar pregnancy. There is no single Beta-hCG
examination reveals a 10-week sized uterus. Beta-HCG is value that is diagnostic for a molar pregnancy. A quantitative Beta-hCG,
80,000 mIU. What is the best next step in the though, is crucial at determining whether or not a pelvic (transvaginal)
management of this patient? ultrasound will confirm a very early gestation. With a Beta-hCG above
the discriminatory zone (>1500 mIU), an IUP should be easily identified
A. Repeat Beta-HCG in 24 hours on transvaginal ultrasound. If an IUP is not seen, the ultrasound findings
B. Repeat Beta-HCG in 48 hours (in conjunction with the Beta-hCG level) should identify a mole (multiple
C. Pelvic ultrasound internal echoes) or an ectopic (absence of intra-uterine gestation).
D. Dilation and curettage Additional Beta-HCG levels are not indicated at this time. Suction
E. Routine prenatal care curettage will provide a pathologic specimen that can distinguish
between a normal and molar pregnancy, but it is used only as a
therapeutic intervention. Routine prenatal care would be appropriate
only after establishing a normal pregnancy.
2. A 17-year-old G0 sexually active female presents to the D. Although all of the tests listed above may be considered, it is
emergency room with acute right lower quadrant pain imperative to obtain a Beta-HCG to rule out an ectopic pregnancy.
and nausea for 12 hours. Her periods have always been
irregular, with her last one six weeks ago. She is
otherwise completely healthy. She appears in mild
distress. Physical examination: temperature 100.2F
(37.9C); blood pressure 110/60; heart rate 108 beats/min.
She has moderate abdominal tenderness with right
greater than left pelvic tenderness. Pelvic examination
reveals normal external genitalia and pink-tinged
discharge is noted on speculum examination.
Bimanual/rectovaginal examination confirms mild
cervical motion tenderness and fullness in the right
adnexa with moderate tenderness and some voluntary
guarding. What is the single most important test to
obtain?

A. Pelvic ultrasound
B. CT scan of the abdomen and pelvis
C. GC and chlamydia DNA probe
D. Beta-hCG
E. CBC with differential
3. An 18-year-old G0 woman presents to
discuss contraception. Her best friend's
mother was just diagnosed with ovarian
cancer. The patient is healthy and does not
have any significant medical history. She
does not have a family history of ovarian,
breast or any other malignancies. She uses
condoms for birth control. She would like to
know what she can do to minimize her risk
for developing ovarian cancer. Which of the
following recommendations is the most
appropriate for this patient?
C. A woman's risk for development of ovarian cancer during her lifetime is
approximately 1%. Factors associated with development of ovarian cancer include low
parity and delayed childbearing. Long-term suppression of ovulation appears to be
protective against the development of ovarian cancer. Oral contraceptives that cause
anovulation appear to provide protection against the development of ovarian cancer.
Five years cumulative use decreases the lifetime risk by one-half. Risk reducing
salpingo-oophorectomy is not a practical choice for this patient with no family history,
even once she completes childbearing. This option might be considered for a woman
with a strong family history and the BRCA mutation.

A. Begin childbearing now

B. Use an intrauterine device
C. Use oral contraceptives until she is ready
to have children
D. Have a risk reducing salpingo-
oophorectomy once childbearing is
complete
E. There are no proven means to reduce the
risk of ovarian cancer
4. A 20-year-old G0 previously healthy woman D. A complete mole has a characteristic "snowstorm" appearance on ultrasound. This
presents to the emergency department with is due to the presence of multiple hydropic villi. This patient has a classic presentation
painless vaginal bleeding. Her last for a molar pregnancy. Vaginal bleeding is universal in molar pregnancies. Uterine
menstrual period was 16 weeks ago. On size greater than dates (weeks from LMP) can be seen in 25-50% of moles, although
physical exam, her vital signs are: size less than dates can be seen in 14-33% of moles. There is no fetus seen in cases of
temperature 98.6F (37.0C); heart rate 120 a complete mole. There can be a fetus, which is usually grossly abnormal, in cases of
beats/minute; and blood pressure 140/90. a partial mole. There is detectable Beta-hCG in molar pregnancies. The Beta-hCG
Abdominal and pelvic examination confirms values are generally higher than the values observed in normal pregnancy. Caution
a 20-week sized uterus with a small amount should be taken against the use of a single-value of Beta-hCG to rule in or out a
of blood in the vagina. Beta-hCG is 68,000 molar pregnancy. However, when combined with the findings of an enlarged uterus
mIU/mL. Fetal doppler tones are not and vaginal bleeding, a Beta-hCG value >1,000,000 mIU/mL may be diagnostic.
auscultated. Which of the following findings Tachycardia from hyperthyroidism (10% serum diagnosis; 1% clinical diagnosis) and
would you expect to see on a pelvic hypertension from preeclampsia (12-25%) can occur in molar pregnancy.
ultrasound of this patient?

A. Fetus with no cardiac activity

C. Multifetal gestation
D. Uterus with a snowstorm appearance
E. Empty uterus with an enlarged, complex
adnexal mass
5. A 20-year-old G0 woman presents requesting
birth control pills. She received the HPV vaccine
series last year, and had her first sexual
encounter last month. Otherwise, she is in good
health and is a non-smoker. Her pelvic
examination reveals normal external genitalia,
and a nulliparous cervix without discharge or
mucosal lesions. A urine pregnancy test is
negative. Which of the following is the
appropriate screening recommendation for this
patient?
A. Return next year for a Pap test
B. Return in three years for a Pap test
C. Perform a Pap test now
D. Perform HPV testing
E. Perform colposcopy
6. A 21-year-old G0 woman presents for her first
pelvic examination. She is completely
asymptomatic, healthy, and reports having only
one sexual partner. She uses condoms for
contraception. On examination, the patient has
a normal appearing cervix except for minimal,
non-malodorous vaginal discharge. Chlamydia
and gonorrhea screening is performed, as well
as a Pap test. The Pap test is read as ASCUS
(atypical squamous cells of undetermined
significance), HPV negative, and her cultures
are negative. Which of the following is the most
appropriate management strategy for this
patient?
A. Repeat the Pap test in 4-6 weeks after
antibiotic treatment for bacterial vaginosis
B. Pap test in one year
C. Pap test in three years
D. Colposcopy with endocervical curettage and
directed biopsies
E. Cervical conization
A. In 2013, the American Congress of Obstetrics and Gynecology (ACOG)
updated the following recommendations for cervical cancer screening:
Cervical cancer screening should start at age 21 years.
Women aged 21-29 years should have a Pap test every three years.
Women aged 30-65 years should have a Pap test and an HPV test (co-testing)
every five years (preferred). It is acceptable to have a Pap test alone every three
years.
Women should stop having cervical cancer screening after age 65 years if they do
not have a history of moderate or severe dysplasia or cancer and they have had
either three negative Pap test results in a row, or two negative co-test results in a
row within the past 10 years, with the most recent test performed within the past
five years.
Women who have a history of cervical cancer, are infected with HIV, have a
weakened immune system, or who were exposed to DES before birth should not
follow these routine guidelines.
ACOG recommends that women who have been vaccinated against HPV should
follow the same screening guidelines as unvaccinated women.
C. The ASCCP (American Society of Colposcopy and Cervical Pathology)
recommends that management options for ASCUS include performing HPV DNA
testing or repeat cytology at 12 months following the abnormal Pap test result. If
the HPV testing is negative (as was reported in this case), then routine screening
can be resumed at three years. If HPV is positive, or if repeat cytology at 12
months reveals ASCUS or higher, then colposcopy should be performed. For
women ages 21-24, if HPV is positive, then repeat cytology at 12 months is
recommended with colposcopy performed only if the repeat cytology reveals
ASC-H (atypical squamous cell - cannot rule out high grade squamous
intraepithelial lesion), AGC (atypical glandular cells) or HSIL (high-grade
squamous intraepithelial lesion). The presence of an underlying infection does not
affect the triage of an abnormal Pap smear but may explain the presence of
ASCUS. See ASCCP guidelines:
http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf
7. A 22-year-old G1P0 woman who underwent
dilation and curettage for a presumed
missed abortion has a pathology report
revealing a partial molar pregnancy.
Compared to a complete mole, which of the
following is true about a partial mole?
A. Karyotype 69XXY, fetus present, higher
risk of developing post-molar GTD
B. Karyotype 69XXY, fetus present, lower
risk of developing post-molar GTD
C. Karyotype 46XX, fetus present, higher
risk of developing post-molar GTD
D. Karyotype 46XX, fetus present, lower risk
of developing post-molar GTD
E. Karyotype 46XX, fetus absent, lower risk
of developing post-molar GTD
8. A 25-year-old G0 woman presents for a
refill on oral contraceptives. She has a
history of recurrent ovarian cysts. She has
no significant medical or surgical history.
Her grandmother was recently diagnosed
with ovarian cancer and her mother is
undergoing treatment for metastatic breast
cancer. The patient is interested in assessing
her risk for ovarian cancer susceptibility.
Which of the following is the most
appropriate test to offer this patient?
B. Molar pregnancies are classified as either complete or partial, depending on several
histologic, pathologic and genetic characteristics. Partial moles may contain fetus/fetal
parts, placenta/cord; complete moles do not. Partial moles are triploid karyotype
(usually 69XXY, 69XXX, or 69XYY) resulting from fertilization of egg by dispermy;
complete moles are diploid resulting from fertilization of "empty egg" by single sperm
(46XX, 90%) or by two sperm (X & Y = 46XY 6-10%). Partial moles show marked villi
swelling; complete moles show trophoblastic proliferation with hydropic degeneration.
Clinically, partial moles present with lower Beta-hCG levels, affect older patients, have
longer gestations, and are often diagnosed as missed or incomplete abortions.
Complete moles usually present with larger uteri, preeclampsia and higher likelihood
of developing into post-molar GTD.
C. BRCA1 and BRCA2 mutations are typically seen in cases of hereditary ovarian
cancers. Overall, it has been estimated that inherited BRCA1 and BRCA2 mutations
account for 5 to 10 percent of breast cancers and 10 to 15 percent of ovarian cancers
among white women in the United States. Given this family history, it is highly likely that
a mutation is present, and the affected individual (proband) should be tested if still
alive. Because breast cancers are part of the BRCA mutation, the affected mother
should be tested. Routine screening for ovarian cancer has not been established.

A. Annual CA125 levels

B. Annual pelvic ultrasound
C. Genetic testing of BRCA1 and BRCA2
mutations on the patient's mother
D. Genetic testing of BRCA1 and BRCA2
mutations on the patient's grandmother
E. Check the patient for p53 mutation
9. A 25-year-old G1 is at 18 weeks gestation. A 2 cm
subserosal fibroid was noted on the anterior fundal
wall of her uterus at the time of her obstetric
ultrasound at 17 weeks gestation. Which of the
following treatment options for the uterine fibroid
is most appropriate?
A. Obtain a follow up ultrasound every six weeks to
follow growth of the fibroid
B. Laparoscopy now to remove the fibroid
C. Perform delivery by Cesarean section at term
D. Perform delivery by Cesarean section at term
with removal of the fibroid after delivery of the
baby and placenta
E. No further treatment is necessary
10. A 25-year-old G1P1 woman comes in for her annual
health maintenance examination. She has
intermittent left lower quadrant discomfort. She
has regular menses every 30 days and uses a
diaphragm for birth control. Her last menstrual
period was approximately three weeks ago. Her
physical examination is notable for a 3 x 5 cm left
adnexal mass. Ultrasound shows a unilocular
simple cyst. Which of the following is the most
likely diagnosis in this patient?
A. Endometrioma
B. Functional ovarian cyst
C. Mucinous cystadenoma
D. Serous cystadenoma
E. Dermoid
11. A 26-year-old G2P1 woman presents with early
pregnancy and vaginal spotting. Her last normal
menstrual period was three months ago, and she
had a positive home pregnancy test two weeks ago.
She has been experiencing severe morning
sickness. She denies any pelvic cramping or
abdominal pain. She is otherwise healthy. On
physical examination, she has a palpable uterus
just above the symphysis. Pelvic examination is
notable for a 2 cm fleshy friable nodular lesion
along the left lateral vaginal sidewall, the cervix is
multiparous, with a small amount of blood in the
vault. Bimanual examination confirms a 10-week
sized uterus. A pelvic ultrasound confirms a
snowstorm pattern, and Beta-hCG is 52,000 mIU.
What is the next step in the management of this
patient?
A. Chest X-Ray
B. Biopsy the vaginal lesion
C. PET scan
D. CT scan of the chest/abdomen/pelvis
E. Evacuation of the uterus
E. Uterine fibroids are the most common solid pelvic tumors in women. On
postmortem examination, fibroids can be detected in as high as 80% of
women. Most uterine fibroids are asymptomatic and do not require any
treatment. Pregnant patients with fibroids usually are asymptomatic and do not
have any complications related to the fibroids. Fibroids may grow or become
symptomatic in pregnancy due to hemorrhagic changes associated with rapid
growth, known as red or carneous degeneration. However, this is uncommon
for smaller fibroids. Uncommonly, fibroids can be located below the fetus, in
the lower uterine segment, or cervix, causing a soft tissue dystocia,
necessitating delivery by Cesarean section. In this case, it is not indicated
given the location of the fibroid. Myomectomy (removal of the fibroid) during
pregnancy is contraindicated. Myomectomy at the time of Cesarean section
should be avoided, if possible, secondary to the risk for increased blood loss.
It is not necessary to follow the growth of fibroids during pregnancy, except
for the rare cases when the fibroid is causing symptoms (primarily pain) or
appear to be located in a position likely to cause dystocia.
B. Functional ovarian cysts are a result of normal ovulation. They may present
as an asymptomatic adnexal mass or become symptomatic. Ultrasound
characteristics include a unilocular simple cyst without evidence of blood, soft
tissue elements or excrescences. An endometrioma is an isolated collection of
endometriosis involving an ovary. This would not classically appear as a simple
cyst on ultrasound. Serous cystadenomas are generally larger than functional
cysts and patients may present with increasing abdominal girth. Mucinous
cystadenomas tend to be multilocular and quite large. Dermoid tumors usually
have solid components or appear echogenic on ultrasound, as they may
contain teeth, cartilage, bone, fat and hair.
D. This patient most likely has metastatic GTD given the constellation of
findings, and elevated Beta-hCG with no evidence of an intrauterine
pregnancy. Although evacuation is likely necessary, the finding of a vaginal
nodule raises the suspicion of metastasis and further warrants a full staging
evaluation with a CT scan of the chest, abdomen and pelvis. A brain MRI is
also likely. A simple CXR would not be sufficient since she already has
evidence of metastasis to the vagina. Since metastatic GTD is known to be
quite vascular, suspicious lesions should not be biopsied. A PET scan has not
been shown to be a preferred method of evaluation at this time.
12. A 28-year-old G0 woman has a high-grade squamous
intraepithelial lesion (HSIL) on a Pap test. She has no
complaints. She smokes one pack of cigarettes per
day. Her pelvic exam is normal. Colposcopy is
performed. The cervix is noted to have an ectropion
and there is abundant acetowhite epithelium.
Mosaicism, punctations and several disorderly
atypical vessels are noted. Three biopsies are
obtained and sent to pathology. Which of the findings
on this patient's colposcopy is most concerning?
E. Punctations and mosaicism represent new blood vessels on end and on
their sides, respectively. Atypical vessels usually represent a greater degree
of angiogenesis and, thus, usually a more concerning lesion. An ectropion
is an area of columnar epithelium that has not yet undergone squamous
metaplasia. It appears as a reddish ring of tissue surrounding the external
os. Acetowhite epithelium can represent dysplasia but, in most cases, is less
concerning than the above vascular changes.

A. Ectropion
B. Acetowhite epithelium
C. Mosaicism
D. Punctations
E. Disorderly atypical vessels
13. A 28-year-old G0 woman with a low-grade squamous D. Cervical conization is indicated in this patient who has a positive ECC.
intraepithelial lesion (LSIL) on a Pap test presents for Hysterectomy is the treatment for invasive cancer. Waiting six months can
evaluation. A colposcopy is performed and is potentially be harmful, as the lesion can progress or a higher-grade lesion
satisfactory. A lesion is seen at 3:00 that turns white might already be present. Cryotherapy will not provide a pathologic
with acetic acid, has punctations and mosaicism, and is specimen to rule out invasive cancer, but can be used to treat cervical
friable. This lesion is biopsied with a pathology report dysplasia once cancer has been completely ruled out and the entire lesion
of CIN 1. The patient's endocervical curettage (ECC) is can be visualized.
positive for a high-grade lesion. Which of the
following is the most appropriate next step in the
management of this patient?

A. Follow up Pap test in six months

B. Repeat colposcopy in six months
C. Cryotherapy
D. Cervical conization
E. Hysterectomy
14. A 28-year-old G1P1 previously healthy woman is
brought into the emergency department by her
husband following a seizure at home. She had been
complaining of a severe headache for two days prior
to this, and had been feeling more and more fatigued
and short of breath since the delivery of their child
three months ago. She has been breastfeeding, and
began to have vaginal spotting one month ago. Her
neurologic and physical examinations are
unremarkable and her pelvic exam reveals a normal
uterus with no adnexal masses. Her work-up reveals
multiple nodules on chest X-ray and within the brain
and liver, suspicious for metastasis. Choriocarcinoma
is highly suspected. Which of the following tests will
confirm the diagnosis in this case?
A. A diagnosis of choriocarcinoma is made once the presence of Beta-hCG
is confirmed. Certainly, intrauterine pregnancy and ectopic pregnancy must
be excluded, but this can easily be done depending on the quantitative
level. In the presence of metastatic disease of unclear primary, the
diagnosis of GTD (choriocarcinoma) must be considered. Ultrasound is
useful in ruling out an intrauterine or ectopic pregnancy, but provides no
information if the Beta-hCG is negative or below the discriminatory zone.
Serum CA-125 is a tumor marker for most epithelial ovarian cancers, but,
because it is non-specific, its possible elevation in this case is not
diagnostic. Because metastatic choriocarcinoma is quite vascular,
suspicious lesions should never be biopsied. Tissue diagnosis is the
standard in establishing a diagnosis of almost all malignancies, with the
exception of choriocarcinoma. Only a positive Beta-hCG in a reproductive-
aged woman who has a history of a recent pregnancy (term, miscarriage,
termination, mole) is necessary to establish the diagnosis.

A. Quantitative Beta-hCG
B. Serum CA-125
C. Transvaginal ultrasound
D. Fine needle aspiration of the liver lesions
E. Biopsy of a chest nodule
15. A 28-year-old G2P0020 experienced her
second miscarriage within 14 months. A recent
ultrasound was notable for two uterine fibroids.
The patient is worried that the fibroids may have
caused her early pregnancy losses. She is
otherwise healthy and has no previous
surgeries. She presents to you for further
consultation. Which type of fibroid is the most
likely explanation of her miscarriages?
A. Submucosal
B. Intramural
C. Subserosal
D. Pedunculated
E. Cervical
16. A 30-year-old G1P1 woman presents to the
emergency department with left-sided
abdominal pain. Physical examination is notable
for a 5 x 6 cm mobile left adnexal mass. An
ultrasound is performed, which shows a left
ovarian mass with cystic and solid components.
Which of the following is the most likely
diagnosis in this patient?
A. Leiomyomas are an infrequent cause of miscarriages and subfertility either by
mechanical obstruction or distortion (and interference with implantation). When a
mechanical obstruction of fallopian tubes, cervical canal or endometrial cavity is
present and no other cause of infertility or recurrent miscarriage can be
identified, myomectomy is usually followed by a prompt achievement of
pregnancy. Submucosal or intracavitary myomas are most likely to cause lower
pregnancy and implantation rates. Presumed mechanisms include: 1) focal
endometrial vascular disturbance; 2) endometrial inflammation, and; 3) secretion
of vasoactive substances. Submucosal fibroids are best treated by hysteroscopic
resection.
D. The most common tumor found in women of all ages is the dermoid. The
median age of occurrence is 30 years, and 80% occur during the reproductive
years. Dermoids may contain differentiated tissue from all three embryonic germ
layers. Dermoid tumors can contain teeth, hair, sweat and sebaceous glands,
cartilage, bone, and fat.

A. Serous cystadenoma
B. Mucinous cystadenoma
C. Endometrioid tumor
D. Dermoid tumor
E. Brenner tumor
17. A 30-year-old G3P1 woman undergoes an B. The recurrent risk for molar pregnancies ranges from 1 to 2%, which is a 20-fold
uncomplicated dilation and curettage for a first- increase from background risk. The risk of recurrence after two molar pregnancies
trimester miscarriage. Pathology reveals a is 10%.
complete mole. The patient's medical history is
significant for chronic hypertension. She has a
history of a previous uncomplicated term
pregnancy and a termination of a pregnancy at
16 weeks gestation with trisomy 18. What is the
risk of her developing a recurrent molar
pregnancy?

A. No increase risk over general population

B. Less than 2%
C. 5%
D. 10%
E. More than 20%
18. A 31-year-old G0 woman has been diagnosed
with uterine fibroids. An ultrasound
confirmed the presence of two intramural
fibroids measuring 5 x 6 cm and 2 x 3 cm that
appear to be distorting the patient's uterine
cavity. The patient has a two-year history of
infertility. She has had a thorough infertility
work up. No etiology for her infertility has
been identified. Which of the following
treatments is most appropriate for this
patient?
A. Hysteroscopy
B. Uterine curettage
C. Gonadotropin-releasing hormone agonist
D. Uterine artery embolization
E. Myomectomy
19. A 32-year-old G3P3 woman had a Pap test
that showed a high-grade squamous
intraepithelial lesion (HSIL). She smokes one
pack of cigarettes per day. She has a history
of three vaginal deliveries and a tubal
ligation. On colposcopic examination, at 12:00
there is an acetowhite lesion with punctations
that extends into the endocervical canal.
Endocervical speculum is unsuccessful at
visualizing the entire lesion. Endocervical
curettage and biopsy of this area is negative.
Which of the following would be the most
appropriate next step in the management of
this patient?
E. Myomectomy is warranted in younger patients whose fertility is compromised by
the presence of fibroids that cause significant distortion of the uterine cavity. A
myomectomy may be indicated in infertility patients when the fibroids are of
sufficient size or location to be a probable cause of infertility and when no more
likely explanation exists for the failure to conceive. Hysteroscopy is a procedure that
involves placing a scope through the cervical os to assess the endometrial cavity.
The patient has already been diagnosed with uterine fibroids that are distorting her
cavity and she has already had a fluid contrast ultrasound, so it is unnecessary to
perform hysteroscopy on this patient. Treatment with GnRH agonists can be useful
to shrink fibroids in anticipation of surgery, or if menopause is expected soon. This
patient desires future childbearing, therefore, its use would not be an appropriate
option. Uterine artery embolization can be recommended for women who have
completed child-bearing because of the unclear long-term effects on fertility.
C. Because the entire lesion cannot be visualized, this colposcopy is unsatisfactory.
Severe dysplasia and even invasive cancer cannot be ruled out. Endocervical
curettage has a relatively low sensitivity (i.e. a high amount of false negatives) and,
therefore, you cannot rule out endocervical disease. The endocervical canal must
be histologically examined. A cervical conization should be performed to obtain a
pathologic specimen. Alternatively co-testing can be repeated at 12 and 24 months.
Cryotherapy may serve to ablate part of the canal, but will not provide a pathologic
sample to assess for dysplasia or to rule out cancer.

A. Repeat colposcopy in two months

B. Cryotherapy ablation of the transformation
zone
C. Cervical conization
D. HPV typing
E. Repeat Pap test in six months
20. A 33-year-old G3P1 woman presents to your office with
a positive home pregnancy test. Her last menstrual
period was 12 weeks ago. Obstetrical history is notable
for a prior full term vaginal delivery and a miscarriage.
Ultrasound reveals multiple internal echoes consistent
with a "snow storm" appearance within the 20-week
sized uterus, as well as bilateral 6 cm multicystic
ovaries. Beta-hCG level is >200,000 mIU/mL. Dilation
and curettage is performed and final pathology reveals
a complete molar pregnancy. What is this patient's risk
of developing persistent (post-molar) gestational
trophoblastic disease?
A. Not at risk
B. Lower than that of a partial molar pregnancy
C. Higher than that of a partial molar pregnancy
D. Same as that of a partial molar pregnancy
E. High enough to mandate prophylactic treatment with
methotrexate
21. A 34-year-old G2P2 woman presents with biopsy-
proven vulvar intraepithelial neoplasia, grade 2 (VIN 2).
She had undergone routine examination by her primary
physician, who performed a Pap smear (normal) and
noted multiple warty-type lesions on the labia. The
patient describes some mild itching that she self-
treated for a yeast infection, with minimal relief.
Otherwise, she is completely healthy, except for
smoking a half-pack of cigarettes per day. She is
sexually active, and is concerned about the impact this
will have on her sex life. Examination confirms multiple,
whitish raised 0.5 - 1.5 cm papules throughout her labial
minora, majora, clitoral hood and perineum. Which of
the following is the most appropriate treatment option
for this patient?
A. Trichloroacetic acid (TCA)
B. Skinning vulvectomy
C. Observation and expectant management
D. CO2 laser ablation of the lesions
E. Smoking cessation
C. Although very effective in evacuating both complete and partial molar
pregnancies, suction curettage provides definitive therapy in the vast
majority of partial moles (>95%). For complete molar pregnancies,
although Beta-hCG levels initially do drop following dilation and
curettage, they can plateau and eventually rise in approximately 20% of
cases. The risk following partial moles is much less (5%). The development
of this post-molar GTD may be due to persistent (retained or invasive)
disease in the uterus or metastatic disease (often to the lungs). The
constellation of findings described in this patient (large uterus, theca
lutein cysts, high Beta-hCG) increases the risk that this molar pregnancy
will persist despite complete evacuation, hence the need for close follow-
up with serial Beta-hCG levels. Persistent disease can easily be cured with
chemotherapy, if it develops, and is therefore not routinely given
prophylactically, except in high-risk situations (e.g. non-compliant patient
who will be lost to follow-up).
D. Given the multifocality of the vulvar dysplasia (VIN 2), laser treatment is
the best choice. In order to adequately treat these lesions, a complete
(skinning) vulvectomy would be the other choice, but would be
disfiguring and require removal of the clitoris which would have
detrimental effects on her sexual function. Treatment with TCA is
recommended for treatment of warts and not VIN. Smoking cessation is
strongly recommended regardless, but would not be the sole means of
addressing these lesions. Observation is not ideal, given her mild
symptoms, moderate grade, and diffuse nature of the lesions.
22. A 34-year-old healthy G3P3 woman presents for a health
maintenance examination. She has not seen a gynecologist
since she had a tubal ligation six years ago. She has been
married for 12 years. She has no history of abnormal Pap
tests or sexually transmitted infections. The patient's physical
examination is normal, except for a small white plaque noted
at the 12:00 o'clock position on her external cervical os. In
addition to obtaining a Pap test, which of the following is the
most appropriate next step in the management of this
patient?
A. Annual Pap tests
B. Pap test in three years
C. Biopsy the lesion
D. Perform a wet mount
E. Perform cervical conization
23. A 35-year-old African-American G0 woman has a family
history of ovarian cancer. Her mother was diagnosed with
ovarian cancer at age 50 and is in remission. The patient had
onset of menarche at age 14. She has used oral
contraceptives for a total of 10 years. She smokes one to two
packs of cigarettes per week. The patient had a LEEP for
treatment of cervical dysplasia. Which of the following places
the patient at greatest risk for developing ovarian cancer?
A. African American race
B. Family history of ovarian cancer
C. Gravidity
D. Late age at menarche
E. Smoking
24. A 38-year-old G1P0 woman undergoes dilation and curettage
for a partial molar pregnancy. The patient and her husband
are very devastated by the loss of this much-desired
pregnancy. Because she feels that her "reproductive clock" is
ticking away, the patient would like to get pregnant as soon
as possible. How long should she wait before attempting
pregnancy?
A. After recovery from the dilation and curettage
B. After the Beta-hCG normalizes
C. After she has one normal menstrual cycle
D. Six months after negative Beta-hCG levels
E. Two years
C. A white plaque found on the cervix is called leukoplakia and
should be biopsied directly or under colposcopic guidance as soon
as possible, regardless of Pap test outcome. Pap tests have a false-
negative rate as high as 20-30%. If there is no evidence of dysplasia
and her Pap test is normal, then routine screening can be resumed.
A wet mount would be indicated if there was evidence of white
discharge. Although cervical conization maybe necessary if high
grade dysplasia is diagnosed, this is not the most appropriate step
in the management of this patient.
B. The events leading to the development of ovarian cancer are
unknown. Epidemiologic studies, however, have identified
endocrine, environmental and genetic factors as important in the
carcinogenesis of ovarian cancer. The established risk factors
include nulliparity, family history, early menarche and late
menopause, white race, increasing age and residence in North
America and Northern Europe. Smoking has not been
demonstrated to be associated with an increased risk of ovarian
cancer.
D. Once evacuation has been accomplished, patients must be
followed regularly with serial Beta-hCG levels to insure
spontaneous regression. Pregnancy should be avoided during this
follow-up period, and for the following six months. Effective
contraception (OCP or other hormonal contraception) is strongly
recommended to prevent confusion in interpreting a rising Beta-
hCG as a post-molar recurrence/progression versus a new,
spontaneous pregnancy. Given this patient's age and desire for a
pregnancy, waiting two years decreases her fertility and increases
her risks of pregnancy complications.
25. A 38-year-old G3P3 woman presents to the office because
she has noted dark spots on her vulva. She states that the
lesions have been present for at least two years and are
occasionally itchy. She has a history of laser therapy for
cervical intraepithelial neoplasia ten years ago, and has not
had a pelvic exam since then. She has had multiple partners
and uses condoms. Her menses are regular and she had a
tubal ligation. She has a history of genital herpes, but has
only one or two recurrences a year. She has smoked since
age 14. On examination, multicentric brown-pigmented
papules are noted on the perineum, perianal region and
labia minora. No induration or groin adenopathy is noted.
The vagina and cervix are normal in appearance. Which of
the following is the most likely diagnosis?
A. Hidradenitis suppurativa
B. Molluscum contagiosum
C. Vulvar intraepithelial neoplasia
D. Melanoma
E. Paget's disease
26. A 39-year-old G1P1 woman comes to see you because of
increased bleeding due to her known uterine fibroids,
especially during her menses. She reports that her bleeding
is so heavy that she has to miss two days of work every
month. She has been using oral contraceptives and NSAIDs.
Her most recent hematocrit was 27%. She is undecided about
having more children. You discuss with her short and long-
term options to decrease her bleeding. What is the next best
step in the management of this patient?
A. Blood transfusion
B. Gonadotropin-releasing hormone agonists
C. Endometrial ablation
D. Uterine artery embolization
E. Hysterectomy
27. A 39-year-old G4P3 woman with an ultrasound report
suggestive of a molar pregnancy is referred for evaluation.
She is asymptomatic. Her uterus is 16-weeks size and her
Beta-hCG is >200,000 mIU/mL. What is the recommended
treatment for this patient?
A. Expectant management
B. Induction with oxytocin
C. Methotrexate
D. Suction curettage
E. Hysterectomy
C. This presentation is classic for human papilloma virus (HPV)
related vulvar intraepithelial neoplasia. Melanoma would be unlikely
to be multifocal and warts have a characteristic verrucous
appearance, although pigmentation can occur. Molluscum, a
poxvirus, is characterized by multiple shiny non-pigmented papules
with a central umbilication. Paget's disease, although multicentric,
does not have brown pigmentation. Hidradenitis is a chronic,
unrelenting skin infection causing deep, painful scars and foul
discharge.
B. The goals of medical therapy are to temporarily reduce symptoms
and to reduce myoma size. The therapy of choice is treatment with a
GnRH agonist. The mean uterine size decreases 30-64% after three
to six months of GnRH agonist treatment. Unfortunately, GnRH
agonist therapy is recommended for only a short period of time (3-6
months) typically before a surgical procedure, or to bridge a woman
who is close to menopause. In this case, it is the best short-term
option. Even though she is anemic, she is asymptomatic and able to
work so a blood transfusion will not be indicated. Although uterine
artery embolization and endometrial ablation effectively reduce
bleeding, pain and fibroid size, they are contraindicated in a patient
who desires future fertility. The failure rate is about 10-15%. A
hysterectomy would obviously take care of her bleeding but would
not be performed if she desires future fertility.
D. Suction curettage is the standard management for molar
pregnancies. Hysterectomy can be considered in women who have
completed childbearing, however, the morbidity of a hysterectomy is
still considered greater than suction curettage. Induction with
oxytocin would result in severe bleeding once cervical dilation and
contractions developed, and expectant management would risk
increased growth and progression of the mole (as well as the similar
unnecessary risk of bleeding.) Methotrexate may become necessary
if she develops post-molar GTD, but not as a sole means of primary
treatment.
28. A 42-year-old G2P2 woman presents to the office
because she recently noticed a pigmented lesion on her
vulva. She does not know how long it has been there and
it doesn't bother her except that she is worried that she
may have warts. Her screening Paps have been negative.
Her prior exams have been reported as normal. She is a
nonsmoker. Examination of her vulva reveals a pigmented,
flat lesion, approximately 1.5 cm in largest diameter at the
base of the right labia. It is non-tender. No induration is
present. Her groin examination reveals no adenopathy.
Her vagina and cervix are well estrogenized and without
obvious lesions. Which of the following is the most likely
diagnosis?
A. Vulvar condyloma
B. Squamous cell carcinoma
C. Melanoma in situ
D. Paget's disease
E. Lichen sclerosus
29. A 44-year-old G0 woman returns to the office for a post
operative check following tumor debulking for stage IIIB
endometrioid adenocarcinoma of the ovary. Her medical
history is significant for diabetes, hypertension, obesity,
hypercholesterolemia and major depression. Which of the
following is the most appropriate next step in the
management of this patient?
A. Hospice
B. Chemotherapy
C. Surveillance
D. Pelvic radiation
E. Second look laparotomy
30. A 44-year-old G1P1 woman was placed on three months
of a GnRH agonist in order to diminish the size of a 5 cm
submucosal myoma and allow it to be accessible to a
hysteroscopic removal. About two weeks prior to surgery,
she was no longer having severe menorrhagia although
the drug side effects were becoming incapacitating
especially the hot flashes. She decides to cancel the
surgery and she stops the GnRH agonist. Which of the
following is most likely to happen to the myoma?
A. Continues to regress
B. Resumes former growth potential
C. Grows but to half of its original size
D. Grows at a more rapid rate
E. Becomes hemorrhagic
C. This lesion may be melanoma and a biopsy must be done to exclude
this diagnosis. The concerning features are the size and irregularity of
the lesion. Melanoma represents 5% of vulvar cancer, which is not
insignificant given the lack of sun exposure and the relatively small
surface area. There is no variability in the coloration, ulceration or
thickening of the lesion to suggest malignancy at this time. Squamous
cell carcinoma is typically not pigmented. Paget's disease is usually
erythematous with a lacy white mottling of the surface. Condyloma
lesions have a characteristic verrucous appearance. With lichen
sclerosus, the skin appears thin, inelastic and white, with a "crinkled
tissue paper" appearance. Although not listed as an option, the most
likely diagnosis is high-grade vulvar intraepithelial neoplasia, which can
have the same clinical appearance.
B. In all patients with advanced ovarian cancer, post-operative
chemotherapy with a combination of a taxane and platinum adjunct is
considered standard of care in the United States. Women who undergo
surgical cytoreduction, followed by chemotherapy, have a better
overall survival rate than those who undergo surgery alone. The overall
response rate in women with advanced ovarian cancer following
surgery and 4-6 cycles of combination chemotherapy with a taxane
and platinum adjunct is 60-80%. The overall five-year survival for
women with stage III and IV disease is approximately 30%. Second
look laparotomy is no longer considered standard of care.
B. Maximal response is usually achieved by three months of GnRH
agonist treatment. The reduction in size correlates with the estradiol
level and with body weight. Hot flashes are experienced by >75% of
patients, usually in three to four weeks after start of treatment,
although they should not persist for longer than one to two months
from end of treatment. After cessation of treatment, menses return in
four to ten weeks, and myoma and uterine size return to pretreatment
levels in three to four months. The regrowth is consistent with the fact
that reduction in size is not due to a cytotoxic effect. However, it is not
true that secondary to the GnRH agonist withdrawal they will grow at a
more rapid rate.
31. A 44-year-old G2P2 woman presents with six months of intermittent vulvar
itching. She denies any bleeding, but does have a whitish discharge. She has
not felt any obvious lumps or sores. She was diagnosed with lupus over 10
years ago and is on prednisone, mycophenolate mofetil (CellCept), and
hydroxychloroquine (Plaquenil). Her periods are irregular and her Pap
smears have been normal, and her last one was 5 years ago. She reports
treatment in the past for warts when she was first diagnosed with lupus, but
denies any other sexually transmitted infections. Examination of the vulva is
notable for diffuse, erythematous labia, with a thin white filmy discharge.
There appears to be subtle but multi-focal, flat, whitish lesions measuring
0.5 - 1 cm on the labia bilaterally. Her remaining pelvic exam is
unremarkable. A saline and potassium hydroxide wet prep is performed and
is negative. What is the most appropriate next step in the management of
this patient?
A. Treatment with oral fluconazole and a topical imidazole
B. Biopsy of the vulvar lesions
C. Treatment of the lesions with topical trichloroacetic acid
D. Wide local excision of the vulva
E. Adjustment of her immunosuppressive therapies
32. A 45-year-old G3P3 woman presents to the office because of a large dark
spot on her vulva. She states that the lesion has been present for at least
two years and is occasionally itchy. She has smoked since age 20. She has a
history of genital herpes, but only has one or two recurrences a year. On
examination, a 2.5 cm lesion is noted. No induration or groin
lymphadenopathy is noted. The vagina and cervix appear normal. There are
no additional lesions noted on colposcopic examination of the vulva. A
biopsy of the lesion returns as vulvar intraepithelial neoplasia grade 3 (VIN
3). What is the most appropriate next step in the management of this
patient?
A. Imiquimod (Aldara) treatment
B. Trichloroacetic acid (TCA) treatment
C. Wide local excision
D. Cryotherapy
E. Radical vulvectomy
B. These lesions most likely represent an HPV-
related condition such as condyloma or vulvar
dysplasia. Women who are on immunosuppressive
therapy are at higher risk of such conditions and
require close surveillance. Although, her history of
prior treatment for warts suggests these could be
condyloma again, their flat, subtle appearance
raises a concern that they may be dysplastic lesions,
and biopsy is indicated. Treatment for presumed
yeast infection is reasonable, given her
susceptibility, but would not be the sole treatment in
this setting of new clinically evident lesions
especially in light of a negative wet prep. Wide
excision is not indicated at this time without a
diagnosis.
C. VIN III should be treated with local superficial
excision. Even with complete removal of all gross
disease, recurrence is still possible and the patient
will need close surveillance. It is inappropriate to do
radical surgery in this setting as cancer has not been
diagnosed. Treatment with TCA and Aldara are
reserved for condyloma, although some studies
have shown utility in the use of Aldara in treating
low grade VIN. Cryotherapy is primarily used to
treat cervical dysplasia.
33. A 45-year-old G5P5 premenopausal woman was initially
seen in your office for work-up and evaluation of a
FIGO grade 3 endometrial cancer that was diagnosed
by her gynecologist. Which of the following is the most
appropriate treatment for this patient?
A. Chemotherapy
B. Radiation treatment
C. Total abdominal hysterectomy, bilateral salpingo-
oophorectomy, bilateral pelvic and para-aortic
lymphadenectomy
D. Supracervical abdominal hysterectomy with ovarian
preservation
E. Medroxprogesterone (Megace)
34. A 47-year-old G2P2 woman comes to see you because
she is concerned that she has uterine fibroids, as she
recently gained about 20 pounds. Her mother had a
hysterectomy for large fibroids that "made her look like
she was 40 weeks pregnant." She has smoked one pack
of cigarettes a day for the last 35 years and reports no
other medical problems. She has normal menstrual
cycles. Her weight is 216 pounds and she is 5 feet 4
inches tall (BMI 37). Her exam is extremely limited by
her body habitus. A Beta-hCG is negative. A pelvic
ultrasound shows a 4 cm intramural fibroid. What is the
next best step in the management of this patient?
A. Obtain a pelvic MRI
B. Perform laparoscopic myomectomy
C. Counsel her on diet and exercise
D. Perform a hysterectomy
E. Recommend bariatric surgery
35. A 47-year-old G3P3 presents with a several month
history of progressive abdominal bloating. She has had
regular menses her entire life, but recently notes her
bleeding to be heavier and occurring "twice a month."
She is otherwise healthy and does not smoke or drink.
On examination, she is 5 feet 5 inches tall and weighs
130 pounds. Her abdominal exam is notable for some
mild distension, but no palpable masses. Her pelvic
examination is notable for a normal appearing cervix, a
deviated, but non-enlarged uterus, and a 10 cm mobile,
non-tender right adnexal mass. An office endometrial
biopsy reveals complex endometrial hyperplasia
without atypia. What is the most likely explanation for
the adnexal mass and the findings seen on the
endometrial biopsy?
A. Fibroid uterus
B. Endometrioma
C. Metastatic endometrial cancer
D. Granulosa cell tumor
E. Theca lutein cyst
C. The recommended components of the surgical approach to an early
endometrial cancer are the extrafascial total abdominal hysterectomy,
bilateral salpingo-oophorectomy, and pelvic and para-aortic
lymphadenectomy. Alternative surgical approaches to early endometrial
cancer include a total vaginal hysterectomy with or without a bilateral
salpingo-oophorectomy in women who are medically unstable or have
contraindications to major abdominal surgery. Ideally, this approach
would only be utilized in patients with well-differentiated endometrioid
adenocarcinomas and avoided in patients with high-grade lesions or
aggressive cell types, such as clear cell or papillary serous carcinomas. A
total laparoscopic hysterectomy, BSO, with or without staging is being
utilized more and more in lieu of the traditional open approach for select
patients in many centers, and is a reasonable alternative. Although
chemotherapy, radiation, and hormonal therapy may be utilized, it is
usually in an adjuvant setting.
C. The mostly likely cause of this patient's weight gain is excessive dietary
intake and lack of exercise. She should be counseled on healthy habits
and quitting smoking. The treatment of asymptomatic relatively small
fibroids is not indicated. She does not qualify for bariatric surgery based
on her BMI. Bariatric surgery may be considered when BMI is greater
than 40, or is between 35 to 39.9 accompanied by a serious weight-
related health problem, such as type 2 diabetes, high blood pressure or
severe sleep apnea.
D. The finding of an adnexal mass in a perimenopausal woman raises the
suspicion of a neoplastic process. Because of the new onset of irregular
bleeding and the finding of hyperplasia, the most likely explanation
would be that of a granulosa cell tumor, an estrogen-secreting tumor. A
theca lutein cyst is typically seen in the setting of pregnancy (molar
pregnancy) and is often bilateral. A fibroid uterus may present with heavy
irregular bleeding, but a pedunculated fibroid mimicking an adnexal
mass is unlikely to present with such a bleeding pattern and has no
correlation with hyperplasia. Severe endometriosis often presents with
dysmenorrhea and is unlikely to develop in the perimenopause.
36. A 48-year-old G2P2 woman complains of
progressively heavier and longer menstrual periods
over the last year. Prior to this year the patient had
normal periods. She denies any symptoms other than
fatigue over the last few months. Physical examination
is unremarkable except for the pelvic examination. The
patient is noted to have an irregularly shaped 16-week
size uterus. The patient's hematocrit is 28%. What is this
patient's most likely diagnosis?
A. Endometrial hyperplasia
B. Endometrial carcinoma
C. Uterine fibroids
D. Uterine leiomyosarcoma
E. Adenomyosis
37. A 48-year-old G3P3 woman recently had an abnormal
Pap test with high grade squamous intraepithelial
lesion (HSIL). Colposcopically-directed biopsy
revealed cervical intraepithelial neoplasia 3 (CIN 3). A
loop electrosurgical excision procedure (LEEP) is
subsequently performed. In reviewing the pathologic
specimen with the pathologist, abnormal squamous
cells are seen extending 2 mm beyond the basement
membrane. What is the patient's diagnosis?
A. CIN 1
B. CIN 2
C. CIN 3
D. Carcinoma in situ
E. Microinvasive cervical cancer
38. A 49-year-old G0 woman reports that her periods have
become heavier over the last year. The patient's
physical exam is notable for a slightly enlarged,
irregularly shaped uterus, measuring approximately
eight weeks in size. A pelvic ultrasound confirms the
presence of two 2 x 2 cm intramural uterine fibroids.
Her endometrial biopsy reveals proliferative
endometrium. The patient's friend recently had a
hysterectomy due to uterine fibroids and menorrhagia,
but she would like to avoid having surgery. She is
interested in the medical options for treating
symptomatic uterine fibroids, but has tried NSAIDs
which did not seem to help much. What is the next best
step in the management of this patient?
A. Aspirin
B. Methotrexate
C. Estrogen
D. Gonadotropin-releasing hormone agonists
E. Indomethacin
C. The patient's history and physical examination is typical for a
perimenopausal woman with probable uterine fibroids. Although it is
possible that she could have underlying endometrial hyperplasia, the
most likely diagnosis is uterine fibroids. Uterine leiomyosarcoma should be
considered in a postmenopausal woman with bleeding, pelvic pain
coupled with uterine enlargement, and vaginal discharge, but it is
exceedingly rare. Endometrial hyperplasia is more common in
perimenopausal women who do not ovulate regularly and
postmenopausal women. Endometrial carcinoma is typically a disease of
postmenopausal women, although 5-10% of cases occur in women who
are menstruating and 10-15% of cases occur in perimenopausal women.
For this reason, she should still undergo an endometrial biopsy.
Adenomyosis may result in a symmetrically enlarged "boggy" uterus, but
usually presents with dysmenorrhea in addition to menorrhagia.
E. Cervical dysplasia is graded based on extent of involvement of the
epithelial layer but does not extend below the basement membrane.
Carcinoma in situ (CIS) represents abnormal cells involving the entire
epithelium to the basement membrane. In cancer, the cells invade beyond
the basement membrane. In microinvasive cancer, they invade less than 3
mm.
D. Growth of uterine fibroids is stimulated by estrogen. Gonadotropin-
releasing hormone agonists inhibit endogenous estrogen production by
suppressing the hypothalamic-pituitary-ovarian axis. They can result in a
40-60% reduction in uterine size. This treatment is commonly used for
three to six months before a planned hysterectomy in an attempt to
decrease the size of the uterus, which may lead to a technically easier
surgery and decreased intraoperative blood loss. In patients who are not
yet menopausal, once the gonadotropin-releasing hormone agonist
therapy is discontinued, the fibroids may grow again with re-exposure to
endogenous estrogen. Thus, this therapy may be most useful for women
who are close to menopause, as this patient is at age 49. Aspirin and
methotrexate are not effective treatments for fibroids. Methotrexate is
used in ectopic pregnancies. Aspirin and indomethacin will likely not help,
as she did not respond to NSAIDs.
39. A 49-year-old G5P5 woman presents for her first health
maintenance examination since she had her last child 10
years ago. She has no health complaints. She has had
two sexual partners. She smokes three to five cigarettes
per day, and has been smoking for the past 15 years.
Last month, her mother underwent a radical
hysterectomy for Stage 1B cervical carcinoma. Her
pelvic examination is normal, except for mucopurulent
discharge and vaginal condyloma. Which of the
following is the patient's greatest risk for developing
cervical cancer?
A. Family history of cervical cancer
B. Smoking history
C. Vaginal condyloma
D. Multiparity
E. Age
40. A 50-year-old G2P2 woman has a history of
menorrhagia, pelvic pain, dyspareunia, dysmenorrhea,
constipation and occasional spotting in between
periods. She has a three-year history of urinary urgency
and frequency. The patient is concerned that she has
fibroids, as her close friend was recently diagnosed
with fibroids. What is the symptom most commonly
associated with leiomyomas?
A. Intermenstrual spotting
B. Menorrhagia
C. Dyspareunia
D. Dysmenorrhea
E. Urinary symptoms
C. The majority of risk factors for cervical cancer are related to HPV
exposure and include early-onset sexual activity, multiple sexual
partners, a sexual partner with multiple partners, history of HPV or other
sexually transmitted diseases, immunosuppression, smoking, low
socioeconomic status and a lack of regular Pap tests. In this patient with
multiple risk factors, the presence of an HPV-related condition (vaginal
condyloma) already indicates infection with HPV. Although the HPV type
associated with condyloma is typically a low risk strain (e.g. types 6 and
11), she is also at risk of having been exposed to high-risk types that are
typically associated with high-grade dysplasia and cervical cancer (e.g.
types 16 and 18).
B. The major symptom associated with myomas is menorrhagia, thought
to be secondary to: 1) an increase in the uterine cavity size that leads to
greater surface area for endometrial sloughing; and/or 2) an obstructive
effect on uterine vasculature that leads to endometrial venule ectasia
and proximal congestion in the myometrium/endometrium resulting in
hypermenorrhea. Other relatively frequent symptoms include pain and
pressure symptoms related to the size of the tumors filling the pelvic
cavity, as well as causing pressure against the bladder, bowel and pelvic
floor.
41. A 50-year-old G3P3 woman complains of
menorrhagia. Physical examination is notable for a
14-week size irregularly shaped uterus. Her
hematocrit is 35%. Which of the following is the next
most appropriate step in this patient's management?
A. Hysteroscopy
B. Endometrial sampling
C. Treatment with GnRH analogue
D. Hysterectomy
E. Myomectomy
42. A 52-year-old G3P2 woman reports vaginal spotting
and bleeding after intercourse for the past 18
months. She stopped having menses at the age of
48 and has not been on hormone replacement
therapy. She also notes new onset low back pain.
She has smoked two packs a day for the past thirty
years. Her last gynecologic exam was 10 years ago.
On physical examination, she is a thin female who
appears older than her stated age. She weighs 120
pounds and is 5 feet 6 inches tall. Her pelvic
examination reveals atrophy of the external
genitalia and vagina, a minimal amount of dark
brown blood in the vault, and a large parous cervix
with a friable lesion on the anterior lip of the cervix.
The uterus is normal size, non-mobile and fixed in a
retroverted position. There are no palpable adnexal
masses, but there is firm nodularity in the posterior
cul-de-sac on rectal examination. Which of the
following is the most appropriate next step in the
management of this patient?
A. Computerized tomography of the lower spine
and pelvis
B. Pap test
C. Colposcopy
D. Cervical biopsy
E. Pelvic ultrasound
B. The majority of patients with uterine fibroids do not require surgical
treatment. If patients present with menstrual abnormalities, the endometrial
cavity should be sampled to rule out endometrial hyperplasia or cancer. This
is most important in patients in their late reproductive years or
postmenopausal years. If the patient's bleeding is not heavy enough to cause
iron deficiency anemia, reassurance and observation may be all that are
necessary. Treatment with GnRH analogues to inhibit estrogen secretion may
be used as a temporizing measure. This is helpful in premenopausal women
who are likely to be anovulatory with relatively more endogenous estrogen.
Treatment with GnRH analogues can be used for three to six months prior to
a hysterectomy to decrease the uterine size and increase a patient's
hematocrit. This may also lead to technically easier surgery and decreased
intraoperative blood loss. Treatment with GnRH analogue can also be used in
perimenopausal women as a temporary medical therapy until natural
menopause occurs. Myomectomy may be an appropriate treatment for a
younger patient who desires future fertility. Hysteroscopy is not indicated at
this point prior to endometrial sampling. Hysterectomy is a definitive
treatment for women who have completed childbearing. Particularly in a
perimenopausal woman, it is important to first rule out an underlying
endometrial malignancy with endometrial sampling.
D. This patient is at high-risk for cervical cancer. Her risk factors include
tobacco use and a poor screening history. The symptoms of postmenopausal
and postcoital bleeding should be taken seriously, and a cervical biopsy of
the suspicious cervical lesion performed. Her physical examination with
fixation of the uterus and thickening of the rectovaginal septum and back
pain suggests involvement of the parametria (Stage II) and possible extension
to the sidewall (Stage III). A Pap test should not be used to exclude cervical
cancer, as it is a screening test and not a diagnostic test, and colposcopy
would not be useful since a clinically visible lesion is already present.
Although a CT scan may ultimately be needed as part of the evaluation of
cervical cancer, a diagnosis must first be made by biopsy. Ultrasonography
may be helpful in the diagnostic evaluation of post-menopausal bleeding,
but not in the setting of an obvious cervical lesion.
43. A 56-year-old G2P2 post-menopausal woman presents
with abnormal vaginal bleeding of four months duration.
The bleeding initially was only light spotting, but has
become heavier, longer and now with bleeding occurring
almost daily. She also notes abdominal bloating. She is
otherwise healthy and takes no medications. On physical
examination, she has a mildly distended abdomen with
fullness in the lower region. On pelvic examination, she
has a multiparous cervix with dark blood in the vaginal
vault. Bimanual and recto-vaginal examination confirms
an eight-week uterus with a separate 10 cm right adnexal
mobile mass. Endometrial biopsy confirms complex
hyperplasia without atypia, and pelvic ultrasound reveals
a 10 cm complex heterogenous mass with solid
components and no ascites. What is the most likely
etiology of the adnexal mass that would also explain the
findings on endometrial biopsy?
A. Dysgerminoma (Germ cell tumor)
B. Granulosa cell tumor (Sex-cord stromal tumor)
C. Papillary serous carcinoma (Epithelial ovarian tumor)
D. Krukenberg tumor (Metastatic carcinoma)
E. Endometrioma
44. A 57-year-old G0 postmenopausal woman presents to
her gynecologist with a complaint of vaginal bleeding
for one week. The patient reports the cessation of
normal menses approximately four years ago. She has
had no previous episodes of irregular bleeding except
when she took hormonal replacement therapy for six
months. She saw her nurse practitioner five months ago
and reports having a normal gynecologic evaluation and
a normal Pap smear. Her past medical history is
significant for hypercholesterolemia and diet-controlled
diabetes mellitus. Physical exam reveals a 5 feet 3 inches
tall, 275-pound woman in no acute distress. Pelvic exam
demonstrated a normal vulva, urethra, vagina and cervix.
Bimanual exam was normal. An endometrial biopsy was
obtained and demonstrated complex atypical
hyperplasia. Which of the following is this patient's
greatest risk factor for developing endometrial cancer?
A. Nulliparity
B. Obesity
C. Postmenopausal status
D. Use of hormone replacement therapy
E. Complex atypical hyperplasia
B. The most likely diagnosis of the adnexal mass that would also explain
the finding of endometrial hyperplasia would be a granulosa cell tumor
(sex-cord stromal tumor). GCT are functional tumors that secrete high
levels of estrogen, which can ultimately stimulate the endometrium to
undergo hyperplastic changes and even lead to endometrial cancer.
Approximately 25-50% of women with GCT will have endometrial
hyperplasia on biopsy, and 5-10% will have endometrial cancer.
Granulosa cell tumors represent 70% of sex-cord stromal tumors and
typically affect women in their 50's (most common type is the adult GCT
- 95%; the juvenile type affects females before puberty). The three main
histologic sub-types of ovarian cancer include germ cell tumors (5%),
sex-cord stromal tumors (1-2%), and epithelial tumors (90%). Germ cell
tumors typically affect women of younger age groups (ages 10-30),
comprise 20-25% of ovarian neoplasms overall (benign and malignant)
and account for 70% of tumors in this age group. Epithelial ovarian
tumors are the most common and can affect women of all ages, but
typically the malignant types occur in women in their sixth decade of
life.
E. Endometrial cancer is a gynecologic malignancy that has easily
identifiable risk factors and typically presents with symptoms that lead
to an early diagnosis. Risk factors include nulliparity, obesity, late
menopause, hypertension and exposure to unopposed estrogens. Of
these risk factors, obesity confers the greatest risk of developing
endometrial carcinoma, especially when the patient is more than 50
pounds over ideal body weight (10-fold increase). However, in this case,
the patient's greatest risk for developing an endometrial cancer is the
presence of complex atypical hyperplasia (CAH) on endometrial biopsy.
If left untreated, this process has approximately a 28% chance of
progressing to an invasive cancer. More importantly, approximately 30%
of women with a diagnosis of CAH will be found to have an invasive
endometrial cancer on final pathology. Most women who develop
endometrial cancer are postmenopausal, but this is less of an issue
because of the finding of CAH.
45. A 58-year-old G2P2 woman presents to your office complaining
of two years of a vulvar rash. She has seen multiple physicians
without a clear definitive diagnosis. The patient has experienced
intermittent pruritus for one year. She has been prescribed "every
yeast medication known" and has also used multiple over-the-
counter products. She was recently given topical steroid cream,
which did not alleviate her symptoms. She is a breast cancer
survivor and was diagnosed and treated one year ago. She is
presently on tamoxifen. No vaginal bleeding has occurred since
her menopause. On examination, her vulva is fiery red mottled
background with whitish hyperkeratotic areas. A distinct lesion is
not seen. No nodularity or tenderness is noted. With the
exception of vaginal atrophy, the rest of her pelvic exam is
normal. What is the most likely diagnosis in this patient?
A. Lichen sclerosus of the vulva
B. Contact dermatitis
C. Yeast vulvitis
D. Psoriasis of the vulva
E. Paget's disease of the vulva
46. A 61-year-old G3P3 woman is diagnosed with stage IIIA papillary
serous adenocarcinoma of the ovary. She is concerned about her
long-term prognosis. Which of the following factors would be
most helpful in determining this patient's prognosis?
A. Volume of residual disease
B. Tumor stage
C. Presence of non-malignant ascites
D. Tumor grade
E. Ovarian tumor diameter
47. A 62-year-old G0 postmenopausal woman is being referred to
your gynecologic oncology colleague after an office endometrial
sample demonstrated a FIGO grade 1 endometrioid
adenocarcinoma. The patient has no significant medical, surgical
or other gynecologic history. She does not smoke and drinks only
occasionally at social events. She takes a multivitamin. Her
physical exam is unremarkable. Which of the following additional
tests is indicated for this patient?
A. Pelvic ultrasound
B. Chest x-ray
C. Pelvic MRI
D. CA-125
E. Serum estrogen level
E. This is a typical description of Paget's disease of the vulva.
Paget's is an in situ carcinoma of the vulva. The association with
breast cancer is significant, but not as high as Paget's disease
of the nipple. It would be unlikely for psoriasis to present this
late in life. Contact dermatitis is unlikely to last for years and
this woman has had therapy for yeast. Lichen sclerosus is
possible and more common, but does not have the
hyperkeratotic overlay and would have more likely responded
to steroid use.
B. The five-year survival of patients with epithelial ovarian
cancer is directly correlated with the tumor stage. The volume
of residual disease following cytoreductive surgery is also
directly correlated with survival. Patients who have been
optimally debulked (generally <2 cm or <1 cm maximal residual
tumor diameter) have a significant improvement in median
survival. Histologic grade of tumor is important. Women with
poorly differentiated tumors or clear-cell carcinomas typically
have a worse survival than those with well to moderately
differentiated tumors. This is especially important in early-stage
disease. Tumor size, bilaterality and ascites without
cytologically positive cells, are not considered to be of
prognostic importance.
B. Once a pathologic diagnosis is confirmed by biopsy, a basic
clinical assessment should ensue in all patients to help define
the extent of the disease. If a careful history and clinical
gynecologic exam suggests that the carcinoma is likely of an
early stage, minimal pre-treatment evaluation is necessary.
Routine evaluation in this setting should include a chest x-ray as
the lungs are the most common site of distant spread. A pelvic
ultrasound is not indicated once a pathologic diagnosis has
been established, although one may have been obtained as
part of the initial evaluation of postmenopausal bleeding.
When there is a low suspicion for advanced disease, a CT scan,
MRI, PET scan, and other invasive and costly tests are not
indicated. A CA-125 may be helpful in predicting those patients
that may have extrauterine spread, but is not absolutely
necessary.
48. A 65-year-old G2P1 woman has been referred to you for E. Enough to think it was endometrial cancer
further evaluation of postmenopausal bleeding. She
initially was seen by her internist after two weeks of
intermittent vaginal spotting. She reports a similar episode
approximately two months ago. A recent exam and Pap
smear were normal. A transvaginal ultrasound showed a
homogeneous endometrial lining measuring 5.0 mm. A
subsequent office endometrial sample was obtained and
returned with rare atypical cells. What is the most
appropriate next step in the management of this patient?

A. Repeat office endometrial sample

B. Follow-up ultrasound in eight to twelve weeks
C. Return visit in three to six months
D. Abdominopelvic CT scan
E. Dilation and curettage
49. A 65-year-old G2P2 postmenopausal woman with a remote
history of stage I, grade 1 endometrial cancer treated with
surgery 15 years ago returns to your office for a health
maintenance examination. During a review of systems, the
patient reports several months of a dry cough, progressive
dyspnea on exertion, and swelling in her legs. She is a non-
smoker, but her now deceased husband smoked heavily.
She saw her family physician, who initially treated her with
a short course of antibiotics; however, because of
persistent symptoms a chest x-ray was obtained and
revealed a bilateral pleural effusion and a suspicious
pulmonary nodule. Her examination is notable for
decreased breath sounds at the lung bases, a normal
abdominal exam, and a pelvic exam without any suspicious
masses or nodularity. She has pitting edema in both of her
lower extremities. What is the most appropriate next step in
the management of this patient?
A. Obtain a Doppler of her lower extremities
B. Refer to oncologist
C. Refer to palliative care
D. Refer to pulmonologist
E. Repeat chest x-ray in three months
50. A 68-year-old G5P5 woman presents for counseling
following the diagnosis of cervical cancer. She has not seen
a physician in 30 years since the birth of her last child. She
has been widowed for three years and has only had sexual
activity with her husband. The patient questions how she
contracted this cancer as she practices excellent perineal
hygiene including the use of talc. Which of the following
most likely explains the pathogenesis of cervical cancer in
this woman?
A. New onset of sexual activity with another partner
B. Past exposure to high risk HPV
C. De novo cervical cancer development
D. Genetic inheritance
E. Exposure to talc
D. Although recurrent endometrial cancer can present as multiple
pulmonary nodules, this patient is unlikely to have a recurrence of her
endometrial cancer given the initial early stage and remote timing of
her cancer diagnosis. The most appropriate next step is to refer her
to a pulmonologist (or cardiologist) for a thorough work-up. The
finding of pleural effusions and lower extremity edema point towards
a cardiopulmonary etiology; however, the finding of a solitary lung
nodule in a patient exposed to second hand smoke certainly
suggests the possibility of a primary lung cancer. Referral to palliative
care would be premature at this point. A Doppler ultrasound to rule
out a deep venous thrombosis is reasonable, but typically of more
utility in the setting of unilateral edema, and still would not address
the need to evaluate her lung findings
B. Sexual transmission of HPV is known to be a necessary event for
the pathogenesis of cervical neoplasia (dysplasia and cancer).
However, exposure to HPV is not sufficient, as other factors come
into play in the ultimate development of cervical disease including
smoking and immunologic factors. In this patient, exposure to HPV
likely occurred earlier in her life, and because she never underwent
screening, persistence of HPV infection ultimately resulted in the
development of cervical cancer. This patient reports only one sexual
partner, and although the risk of HPV correlates with the lifetime
number of sexual partners, the risk is still relatively high even in those
with one partner (up to 20%). At least 75 to 80% of sexually active
women will have acquired a genital HPV infection by age 50. Cervical
cancer is not genetically inherited. The use of talc does not increase
risk of cervical cancer. Although nothing can be done to reverse the
events that led to the development of this cancer in this individual,
patient education in prevention and screening for cervical neoplasia
should be practiced among all patients.
51. A 68-year-old woman with a history of
breast cancer presents for evaluation of
endometrial cancer risk. She was treated
with lumpectomy and axillary node
dissection and radiation therapy. She has
been on tamoxifen therapy for the past year.
She denies any vaginal bleeding or
discharge. She is 5 feet 3 inches tall and
weighs 140 pounds. Her pelvic examination is
notable only for severe vulvovaginal
atrophy. What is the next best step in the
management of this patient?
A. Endometrial biopsy now to obtain a
baseline
B. Annual endometrial biopsy
C. Annual exams
D. Annual pelvic ultrasound
E. Endometrial biopsy upon completion of
five years of tamoxifen therapy
52. A 69-year-old G3P3 comes in for a health
maintenance examination. Her younger
sister was recently diagnosed with
endometrial cancer and she is concerned
about her risk. Your patient experienced her
last menstrual period at age 49, and she has
not had any bleeding since. Her medications
include only a multivitamin and
supplemental calcium. She has no other
significant family history. Her physical
examination including a pelvic examination
is normal. She is 5 feet 5 inches tall and
weighs 120 pounds. What is the most
appropriate management for this patient?
A. Endometrial biopsy
B. CA125 level
C. Ultrasound with measurement of the
endometrial lining
D. Annual exams
E. Refer to genetic counselor for risk
assessment
C. Tamoxifen is known to increase the risk of endometrial cancer. However,
diagnostic studies, such as endometrial biopsy, are reserved for when the patient
develops symptoms of bleeding or abnormal vaginal discharge. Ultrasound is not
helpful because Tamoxifen is known to cause changes to the endometrium, including
thickening. Endometrial biopsy is not indicated as a screening tool for endometrial
cancer.
D. Less than 5% of women diagnosed with endometrial cancer are asymptomatic.
Approximately 80-90% of women with endometrial carcinoma present with vaginal
bleeding or discharge as their only presenting symptom. Since this patient does not
have any symptoms or risk factors for endometrial cancer, she does not need to
have any diagnostic testing. Risk factors for endometrial cancer include late
menopause, unopposed estrogen therapy, nulliparity, obesity, Tamoxifen therapy and
diabetes mellitus. Although sometimes associated with Hereditary Non-polyposis
Colorectal Cancer Syndrome (HNPCC, or Lynch II), endometrial cancer is typically
not a genetically-inherited malignancy, and so genetic counseling for risk assessment
would not be recommended unless a more significant family history existed.
Endometrial cancer ranks as the fourth most common cancer detected in women in
the US. In 2010, according to the American Cancer Society, there will be an estimated
43,470 new endometrial cancer cases. It is the most common gynecologic
malignancy.
Top Five Cancers Detected in Women:
Breast 28%
Lung 14%
Colon 10%
Uterine 6%
Ovary 3%
Gynecologic Cancers:
Uterine 52%
Ovary 26%
Cervix 14%
Vulva 5%
Vagina 3%
53. A 72-year-old G3P2 postmenopausal woman is referred by her
internist after work-up for abdominal bloating revealed a large
pelvic mass on transvaginal ultrasound and an elevated CA-125.
The patient had a normal colonoscopy and mammography two
months ago. The patient's greatest complaint is early satiety and
upper abdominal discomfort. Her physical exam is notable for
moderate abdominal distension and a significant fluid wave.
Pelvic examination confirms a smooth, but fixed pelvic mass
filling the cul de sac and extending to the umbilicus. Which of
the following tests would be most helpful in assessing the extent
of disease?
A. Barium enema
B. PET scan
C. CT scan of abdomen and pelvis
D. Chest X-ray
E. Intravenous pyelogram
54. A 72-year-old G3P3 presents to the emergency room
complaining of abnormal vaginal discharge for the past two
months. She has had two episodes of vaginal bleeding over the
last year. She used combination hormone replacement therapy
for 10 years when she went through menopause at age 58, but
stopped once the Women's Health Initiative report came out. Her
last gynecologic exam and Pap smear were two years ago and
were normal. She has tried several over-the-counter antifungal
creams for what she presumed was a yeast infection; however,
she reports no change in the nature of the discharge. She does
note that she has some mild lower abdominal discomfort. The
only significant finding on exam is a mucopurulent discharge
from a multiparous cervical os. She has a 10-week sized globular
uterus. Which of the following findings is most concerning for
presence of endometrial cancer?
A. Vaginal bleeding
B. Late menopause
C. Abnormal vaginal discharge
D. Enlarged uterus
E. Hormone replacement therapy
55. A 72-year-old woman presents to the office reporting a history
of vulvar itching that has been worsening over the last six
months. She has a long history of lichen sclerosus, for which she
has not been receiving treatment. On exam, you find an
irregular-shaped lesion which measures 3.5 cm in greatest
dimension, suspicious for malignancy. You perform a punch
biopsy at the edge of the lesion and send it for pathologic
evaluation. The pathologist reports an invasive moderately
differentiated squamous cell carcinoma. Which of the following
is the most appropriate treatment for this patient?
A. Treatment with a topical steroid
B. Radical vulvectomy and groin node dissection
C. Excisional biopsy
D. Laser vaporization of the lesion
E. Cryotherapy
C. The most useful radiologic tool for evaluating the entire
peritoneal cavity and the retroperitoneum is computerized
tomography. Specifically in this patient, it would be important to
look for significant involvement of the omentum. A chest x-ray
provides adequate evaluation of the chest, unless it is abnormal.
If there is a suspicion for chest involvement on the chest film,
then a chest CT is necessary. With a normal colonoscopy and no
symptoms suggestive of colonic obstruction, a barium enema
would not be useful. PET scan, to date, has not been shown to
play a role in the initial evaluation of women with a suspected
ovarian malignancy. However, PET scan may play a role in
evaluating women with a known diagnosis of ovarian cancer
who have a suspected recurrence. An IVP would be useful if
there was suspected ureteral obstruction, but otherwise is quite
limited in assessing the entire abdominal/pelvic cavity.
A. Endometrial cancer is a disease that typically presents with
symptoms and clinical findings that lead to an early diagnosis.
The most common symptom is abnormal postmenopausal
bleeding. However, other symptoms or clinical findings that may
be seen include abnormal vaginal discharge and lower
abdominal discomfort. Endometrial cancer can increase the size
of the uterus as it grows, but is usually not the most common
finding given the early diagnosis of this cancer. Unopposed
estrogen replacement therapy does increase the risk, but not
when taken in combination. Early menarche and late menopause
are additional risk factors that may be related to endometrial
cancer development.
B. Given the findings of obvious, moderately differentiated
carcinoma, definitive treatment can be recommended with
radical vulvectomy and groin node dissection. Only
microinvasive squamous cell carcinoma of the vulva can be
treated by wide local excision, but it is a diagnosis that is only
made after pathology evaluation of a small (<2 cm), well-
differentiated lesion, with invasion <1.0 mm. Excisional biopsy is
not indicated given the larger lesion and confirmed finding of
cancer. It would be inappropriate to laser a malignant lesion.
Squamous cell carcinoma is the most common vulvar
malignancy and may arise in the setting of chronic irritation from
lichen sclerosus. Steroids would treat the lichen sclerosus, but
would only result in needless delay in treatment of the
malignancy. Cryotherapy is not an acceptable treatment for
squamous cancer of the vulva.
56. A 74-year-old G2P2 post-menopausal woman presents for a
health maintenance examination. She notes the new onset of
a lump in her vagina, but denies any pain, abnormal bleeding
or vaginal discharge. She has well-controlled diabetes
mellitus and hypertension. She is recently sexually active
with a new partner since the death of her husband three
years ago. She smokes a half-pack per day, and has done so
since age 18. On examination, she is noted to have a
somewhat firm and fixed non-tender 4 cm mass in her labia
majora at the level of the Bartholin gland on the right. There
is no associated erythema or discharge, and the remaining
vulvar exam and pelvic exam are unremarkable. Her groin
examination reveals no adenopathy. What is the most likely
diagnosis?
A. Lipoma
B. Fibroma
C. Bartholin gland cyst
D. Bartholin gland abscess
E. Bartholin gland malignancy
57. An 81-year-old G3P3 presents to your office with a history of
light vaginal spotting. She states this has occurred recently
and in association with a thin yellow discharge. She never
experienced any vaginal bleeding since menopause at the
age of 52, and denies ever having been on hormone
replacement therapy. She is otherwise reasonably healthy,
except for osteoporosis, well-controlled hypertension, and
diabetes. She is physically active and still drives to all her
appointments. She is no longer sexually active since the
death of her husband two years ago. On examination, she is
noted to have severe atrophic changes affecting her vulva
and vagina. A small Pederson speculum allows for
visualization of a normal multiparous cervix, and the
bimanual examination is notable for a small, mobile uterus.
Rectovaginal exam confirms no suspicious adnexal masses or
nodularity. Which of the following is the most appropriate
management for this patient?
A. Pelvic transvaginal ultrasound
B. Office endometrial biopsy
C. Reassurance and observation for further bleeding
D. Vaginal estrogen therapy
E. Clindamycin vaginal cream
E. The finding of a mass in the Bartholin gland is highly suspicious
for malignancy and requires excision/biopsy, especially in a post-
menopausal women. Primary vulvar adenocarcinomas most likely
arise from the Bartholin gland, but other histologies such as
squamous cell, transitional, adenosquamous, and adenoid cystic
carcinomas can also arise from this location. This is unlikely to be a
fibroma or lipoma given the recent onset and fixed nature of the
mass. A benign Bartholin gland cyst is also unlikely given the
patient's age and rather abrupt onset, and any finding of a new
Bartholin gland cyst in a post-menopausal woman should be further
investigated. For any woman over the age of 40 with a mass in this
area, a biopsy should be obtained. This is not an abscess given the
absence of signs and symptoms of cellulitis or infection.
B. Postmenopausal bleeding or discharge accounts for the
presenting symptom in 80-90% of women with endometrial cancer.
However, the most common causes of postmenopausal bleeding
are atrophy of the endometrium (60-80%), hormone replacement
therapy (15-25%), endometrial cancer (10-15%), polyps (2-12%), and
hyperplasia (5-10%). Any history of vaginal bleeding requires a
thorough history, physical/pelvic examination, and assessment of
the endometrium. This is ideally done via office endometrial
sampling as part of the initial work-up. The use of pelvic
transvaginal ultrasound can provide useful information as to the
presence of any structural changes (polyps, myomas, endometrial
thickening), and for which a diagnosis of endometrial cancer would
be less likely if the endometrial thickness is < 5 mm. Although this
patient is likely to have atrophy as the cause of her spotting, a thin
endometrial stripe does not exclude the possibility of a non-
estrogen dependent carcinoma of the atrophic endometrium.
Vaginal estrogen or clindamycin are not indicated.
58. An 88-year-old G2P2 woman is brought in for evaluation of blood found
in her diapers. She is a nursing home resident and has a long-standing
history of incontinence. This is the first time that her caregivers have
noted blood. They describe it as "quarter size." Her nurses think that she
may have been itching, as they frequently find her scratching through the
diaper. On review of her medical record, biopsy-documented lichen
sclerosus of the vulva was diagnosed fifteen years ago. She has not been
on any therapy for this condition for years. Examination of the external
genitalia reveals an elevated, white, firm irregular lesion arising from the
upper middle left labia. The lesion measures 2.5 cm in greatest dimension.
The remainder of the external genitalia shows evidence of excoriation of
thin, white skin with a wrinkled parchment appearance. The vagina and
cervix are atrophic. No masses are noted on bimanual or rectovaginal
exam and a sample of her stool is negative for blood. No adenopathy is
noted in her groin. Which of the following is the most appropriate next
step in the management of this patient?
A. Begin topical steroids
B. Begin topical benadryl
C. Biopsy the lesion
D. Obtain cultures of the lesion
E. Complete vulvectomy and lymph node dissection
59. An 88-year-old woman is brought in for evaluation of blood found in her
diapers. She is a nursing home resident and has a history of lichen
sclerosus of the vulva, which was diagnosed fifteen years ago. She quit
smoking in her fifties. Examination of the external genitalia reveals an
elevated, firm, erythematous, ulcerated lesion arising from the left labia,
measuring 2.5 cm in greatest dimension. What is the most likely diagnosis
in this patient?
A. Malignant melanoma
B. Squamous cell carcinoma
C. Lichen sclerosus
D. Paget's disease
E. Verrucous carcinoma
60. An obese 30-year-old G3P1 Asian woman undergoes an uncomplicated
dilation and curettage for a first-trimester miscarriage. Pathology reveals
a molar pregnancy. The patient's medical history is significant for chronic
hypertension. She has a history of a previous uncomplicated term
pregnancy, and termination of a pregnancy at 16 weeks gestation for
trisomy 18. What aspect of the patient's history places her at increased
risk for a molar pregnancy?
A. Obesity
B. Previous history of fetal aneuploidy
C. Asian race
D. Chronic hypertension
E. Prior term pregnancy
C. The most important step is to first biopsy the lesion.
It would be inappropriate to treat the lichen sclerosus
first with steroids, as the lesion is suspicious for
malignancy. Treatment with benadryl would also be
inappropriate given the suspicious nature of the lesion.
Diagnostic studies such as cultures and cytology of
such a lesion are not appropriate given the exophytic,
nodular lesion seen on examination. A biopsy should
be performed to make a definitive diagnosis and rule
out malignancy. It would also be inappropriate to treat
the patient with a vulvectomy and lymph node
dissection before obtaining a clear diagnosis.
B. Squamous cell carcinoma accounts for
approximately 90% of vulvar cancers. Patients
commonly present with a lump and they commonly
have a long-standing history of pruritus. The chronic
itch-scratch cycle of untreated lichen sclerosus, or any
other chronic pruritic vulvar disease, is thought to
stimulate the development of squamous carcinoma.
The mean age of squamous cell carcinoma is 65 years
and smoking is known to increase the risk of
development of vulvar cancer, especially in the setting
of HPV infection. With lichen sclerosus, the skin
appears thin, inelastic and white, with a "crinkled tissue
paper" appearance. Paget's disease of the vulva is
associated with white plaque-like lesions and poorly
demarcated erythema, not a discrete mass. Verrucous
carcinoma has cauliflower-like lesions. Melanoma
typically presents as a pigmented lesion.
C. The incidence of molar pregnancy is approximately
1 per 1,500-2,000 pregnancies among Caucasians in the
United States. There is a much higher incidence among
Asian women in the United States (1/800.) Molar
pregnancy occurs more frequently in women less than
20 or older than 40 years of age. The incidence is
higher in areas where people consume less beta-
carotene and folic acid. There is no known association
between molar pregnancy and obesity, a previous
history of fetal aneuploidy, chronic hypertension and
parity. The risk of having a molar pregnancy is
increased in women with two or more miscarriages.
 Unit 7: Violence against women
Study online at quizlet.com/_2isg3p

1. A 3-year-old girl is taken to see her primary care physician by her father, B. Yeast infections are common after antibiotic
secondary to vaginal discharge and swelling of the vulvar area for the past therapy. Scratching can appear like abuse is taking
week. She has been scratching the area and says it hurts. She was on an place. To examine a child, even with a nasal
antibiotic two weeks ago for an ear infection. The child has had normal speculum, is traumatic. If a foreign body is suspected,
growth and development. She has two male siblings, ages 8 and 6. Her an exam under anesthesia may be necessary, if
father is a stay-at-home dad and her mother is an attorney. Examination ultrasound is not successful or indicated.
reveals a red and swollen vulva with linear abrasions over the area. Which
of the following is the most appropriate next step in treatment?
A. Check a complete blood count
B. Begin antifungal treatment
C. Perform nasal speculum vaginal examination
D. Refuse to treat until mother is present
E. Notify police
2. A 4-year-old girl is taken to see her pediatrician by her father. He states B. Children will often place foreign objects in any
that he has noticed a foul odor in the area of the child's "private parts." He body orifice. Toilet paper is the most common foreign
brings in a pair of panties with a brown-yellow stain that has a "funny body found.
smell." The girl is otherwise healthy. Which is the most likely cause of this
condition?
A. Child abuse
B. Foreign body
C. Yeast infection
D. Pinworm infection
E. Urinary tract infection
3. A 6-year-old girl in kindergarten has begun to bed-wet after having been B. Child abuse can happen in any circumstance. It is
toilet trained for three years. She has also been found "playing with herself" not always the "boyfriend" who commits such a crime.
for the past several weeks. In a private conversation the child states, "My Often the perpetrator is a "pillar of the community."
daddy has been playing with me down there." Which of the following is the The child must be able to talk in a safe environment,
most appropriate course of action at this time? certainly not in the presence of the person accused
A. Suggest family counseling of the deed.
B. Notify police
C. Speak with her kindergarten teacher
D. Speak with both parents and child together
E. Admit the child to the hospital
4. A 10-year-old girl has been drawing sexually explicit pictures during art D. Children who are sexually abused will often "act
class. Her behavior in class has ranged from being shy to being aggressive out" and behave inappropriately. There is often no
with her fellow students. She won't go to the bathroom unless someone evidence of physical injury and a careful history must
goes with her. Physical examination shows a normally developed girl. Breast be taken. Asperger's syndrome is an autism spectrum
budding is occurring and she has wisps of axillary and pubic hair. She will disorder in which problems with social interaction
not let you "look at her bottom." Which of the following is the most likely occur and may include physical clumsiness and
cause of this condition? atypical use of language. Symptoms of childhood
A. Normal adolescent development depression may be similar to those seen in adult
B. Asperger's syndrome depression.
C. Precocious puberty
D. Child abuse
E. Childhood depression
5. A 17-year-old G0 was kissing her 18-year-old boyfriend in a parked car. She refused to C. Rape is characterized by lack of consent
have sexual intercourse and he overpowered her, hit her on the face and raped her. He or inability to give consent. Most
did not use a condom and ejaculated inside her. Which of the following made this case definitions include the use of physical
a rape? force, deception, intimidation or the threat
A. Failure to use effective barrier contraception of bodily harm.
B. Sexual intercourse
C. Lack of consent
D. Legal age of the woman
E. Legal age of the boyfriend
6. An 18-year-old college student is brought to your office by her roommate who found C. In a case of date rape, the best course
her sobbing in their room. The student states that she was sitting on a couch with her of action is to ensure that the patient does
new boyfriend. He gave her something to drink. She thinks that she passed out and not get pregnant. The patient should also
awoke two hours later and was undressed. She is afraid that she may have had have screening for sexually transmitted
intercourse. She is not on any form of contraceptive. Her last menstrual period was diseases, with consideration to being
two weeks ago. Examination reveals no obvious injuries and a vaginal swab shows offered antibiotic prophylaxis. Although
motile sperm. In addition to providing counseling and screening for sexually the risk of infection is unknown among
transmitted infections, which of the following is the most appropriate next step in victims of sexual assault, it may be higher
management? compared to consensual sexual
A. Discuss her responsibility to report this to her college encounters.
B. Admit to the hospital for intravenous antibiotics
C. Recommend emergency contraception
D. Notify her college advisor
E. Obtain more information from her roommate
7. An 18-year-old college student is seen in the emergency room, claiming she was B. Women who are raped are often in
raped by a 29-year-old janitor in her dorm four hours ago. He threatened her with a denial or shock. A woman may shower
knife and she did not resist. She appears calm and has a flattened affect when the after an attack, destroying evidence in an
history is taken. Currently, she is sexually active with a fellow student and is taking attempt to deny what happened or to
birth control pills. The alleged attacker used a condom, which she helped him put on. "clean herself." She may blame herself for
The student is 5 feet 2 inches tall and weighs 110 pounds. She is a cheerleader for the the attack and feel she should have
college football team. Examination reveals no bruising and gynecologic examination resisted more.
reveals no apparent injuries. Which of the following statements is the most likely
explanation for this patient's presentation?
A. The attack was not emotionally traumatic
B. The student is in shock
C. The attack never happened
D. The student cooperated with the attacker
E. The student suffers from chronic depression
8. A 24-year-old woman comes to her physician for help with her
premenstrual syndrome symptoms. She complains of "not being herself"
for three to four days before her period and has episodes of crying and
irritability. She denies depressive symptoms and notes she is a stay-at-
home mother for her three children. After a complete history and
physical examination, the patient is prescribed a selective serotonin
reuptake inhibitor but, after three months, she returns as there is no
change in her symptoms. Upon further discussion, the patient admits
that her husband has a bad temper at times. Physical examination is
normal with the exception of some bruising on the patient's arms. She
claims that she fell and that she is often clumsy. Which of the following is
the most appropriate next step in the management of this patient?
A. Report the injuries to the police
B. Offer domestic violence resources to the patient
C. Refer the patient for a psychiatric consultation
D. Refer the patient to the emergency department for further evaluation
E. Arrange to move her children to a home of a close friend or family
member
9. A 28-year-old G1P0 presents to the emergency room at 2 am stating
that, while having sex with her husband, she started to have severe
vaginal bleeding. She has minimal pain, but is concerned that the
bleeding won't stop. On examination, she is mildly anxious and appears
embarrassed. Her vital signs are notable for a blood pressure of 118/62
and pulse of 104. Her abdominal exam is benign, and her pelvic exam is
notable for a laceration along the posterior vaginal wall extending into
the fornix. Active bleeding is occurring. When further questioned, she
admitted to using a new sexual toy that she and her husband wanted to
try out during intercourse. Which of the following is the most
appropriate next step in management?
A. Transfuse the patient with packed red blood cells immediately
B. Repair the laceration under anesthesia
C. Obtain cultures for sexually transmitted infections
D. Provide emergency contraception
E. Notify the police
10. A 30-year-old G2P2 was raped by a stranger while she was walking
through a park alone at 2:00 am. The assailant did not use a condom. An
intern evaluated the patient in the emergency room. He took a detailed
history, performed a complete physical exam and collected forensic
specimens. He obtained cultures for gonorrhea and chlamydia, and
obtained an RPR, hepatitis antigens, an HIV test, a urinalysis and culture,
and a pregnancy test. He provided the patient with postcoital
contraceptive medication. Which of the following additional actions is
most appropriate?
A. Notify police
B. Notify the patient's parents or her closest relative or friend
C. Offer the patient antibiotic prophylaxis for sexually transmitted
infections
D. Counsel the patient regarding the practice of "safe behavior,"
including not walking in deserted areas alone
E. Offer the patient testing for herpes simplex virus (HSV)
B. Victims of domestic violence frequently present with
vague physical and emotional complaints that are
consistent with PMS. Victims will rarely volunteer
information on first physician encounters, but
subsequent visits give opportunities to offer resources
for assistance. It is the patient's choice as to whether she
would like to involve the police. Social work
consultation, family counseling and relocation are all
reasonable options that fall under the resources that
may be discussed with the patient, but must be arranged
at the patient's request and with her consent. Emergency
department evaluation or physchiatric consultation are
not indicated at this point.
B. Sexual trauma and vaginal lacerations can occur
during consensual sexual behavior and do not
necessarily indicate sexual abuse. However, aggressive
sexual activity can result in serious injuries, especially if
mechanical or foreign objects are not safely used.
Exploration and repair of this injury should be done in
the operating room under general anesthesia. A blood
transfusion may be indicated, depending on her blood
count and estimated blood loss, but may not be
necessary. Testing and treatment for sexually transmitted
infections or emergency contraception should be
discussed with the patient, as not all cases of sexual
trauma are due to abuse/assault.
C. Antibiotic prophylaxis should be offered to all adult
rape victims. Although patients are often reticent to do
so, they should be gently encouraged to work with the
police. This has been associated with improved
emotional outcomes for victims. Counseling the patient
regarding the practice of "safe behavior" at this time may
make the patient feel blame, when the blame should be
placed on the rapist. HSV antibody testing is not
indicated.
11. A 35-year-old woman presents for a health maintenance examination. She is present D. Domestic violence does not always have
with her husband who appears to be over-bearing and answers all the questions for to manifest in physical abuse.
her. She defers to him without resistance. During the examination, he gladly leaves the Disagreements and arguments, even
room. Her examination is entirely normal without any signs of bruising, trauma, or heated discussions, are part of a normal
injuries. When you ask her if she is in a relationship with a person who threatens or relationship. However, physical violence or
physically hurts her, she denies this and quickly dresses and leaves the exam room to other abusive behaviors are not. Signs of
meet her husband who is waiting for her outside the room prior to checking out. The being involved in an abusive relationship
following month, she returns again for an appointment alone to discuss "private may come in several forms and screening
matters." She is worried that her husband will leave her if she refuses to have sex with all women at routine ob-gyn visits, during
him even though she doesn't want to, and states he gets angry easily and throws family visits and during preconception
things. She loves him dearly and admits that they do have frequent disagreements, visits are recommended by the American
but he has never hit her. She is worried that he might find out that she is seeing the College of Ob-Gyn (ACOG). For the
doctor alone, and had to sneak out without him knowing. Which of the following is pregnant woman, screening should occur
LEAST likely to be a sign that she is in an abusive relationship? at the first prenatal visit, at least once per
A. Being frightened by threats of violence trimester, and at the postpartum checkup.
B. Having objects thrown by partner when angry
C. Being restricted from contacting family or friends
D. Having frequent disagreements
E. Having sex when not wanting to
12. A 79-year-old woman is seen in the emergency room in a comatose state. Her A. In a case of obvious elderly abuse,
daughter states that her mother is always wandering away from the home. She has social services must be notified. Physicians
tried to tie her to her bed, but has found that if she gives her zolpidem (Ambien) must be aware of the social services
every four hours, it keeps her sedated. The daughter works during the day and would available for their patients. The patient
put her mother in a nursing home, but she needs the mother's social security check to should not be taking zolpidem, and this
maintain the household. Examination reveals an unresponsive, thin, dehydrated should also be discontinued. The patient
woman with acute and chronic bedsores. After hydration and treatment of her skin may ultimately be discharged home or
condition in the hospital, which of the following is the most appropriate next step? possibly to a skilled nursing facility,
A. Notify social services depending on her needs, which should be
B. Notify hospital security done in consultation with social services
C. Discharge patient to hospice and discharge planning. At this time,
D. Consult psychiatry hospice or consultation with psychiatry are
E. Decrease the zolpidem dose not indicated.
13. An 84-year-old woman is seen in the emergency department because of a pain in her B
right arm. She is widowed and lives with her daughter, who states that her mother is
"always falling down" and is becoming forgetful. She would put her in a nursing home,
but her mother's social security check is needed for family expenses. She has a
history of breast cancer treated by mastectomy 15 years ago, and took tamoxifen for
five years. The patient is on zolpidem (Ambien) 10 mg for sleep. She has been unable
to afford the bisphosphonates needed for bone loss. Examination reveals a cachectic
white woman, 5 feet 2 inches tall, weighing 94 pounds. She has tenderness in her right
forearm with swelling. She is also noted to have old and new bruises on her chest and
arms. An x-ray of the right arm reveals a spiral fracture. Which of the following is the
most likely cause of the bone fracture?
A. Osteoporosis
B. Elder abuse
C. Bone metastasis from occult breast cancer
D. Malnutrition
E. Falls due to unsteadiness
14. A mother brings in her 6-year-old daughter for an examination. She states that she B. In all suspected cases of child abuse, the
thinks her boyfriend may be "fooling around" with the child. The girl runs and proper authorities must be notified. Often
hides when the boyfriend comes to their home. Examination reveals a normal 6- victims of child abuse have no physical
year-old girl. There is no evidence of sexual abuse. The mother wants nothing findings. Colposcopic examination is often
done as she is dependent on her boyfriend for support. Which of the following is inconclusive. The child may be acting out, but
the most appropriate course of action? it is better to err on the side of safety.
A. Advise return visit in one month
B. Notify police
C. Advise family counseling
D. Inform mother that the child may be jealous
E. Perform colposcopic examination
15. A representative from a domestic violence outreach program asks for your help in C. The best place to have literature is where
distributing information, to include a hot line to call, if needed. Where is the best there is the most privacy such as an office
place for this information to be made available? restroom. In the other areas cited, an abuser
A. Office waiting room may see the information and prevent his/her
B. Distribution to all patients at time of check in spouse or partner from obtaining it.
C. Office restroom
D. Letters sent to all your patients
E. Posters in front of your office