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    50 MCQS OB/GYN with explanations

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    hey everyone. a very helpful user named "me" tried to post this on another forum but it was deleted. i downloaded it before it was deleted so now i'm posting it for all you guys here. i also uploaded this file in the free downloads area along with some others. i will continue to do this for you guys. just remember to share .

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    Block 18 Explanations
    1) A 31-year-old woman comes to the physician for follow-up after an abnormal Pap test and cervical biopsy. The patient's Pap test showed a high-grade squamous intraepithelial lesion (HGSIL). This was followed by colposcopy and biopsy of the cervix. The biopsy specimen also demonstrated HGSIL. The patient was counseled to undergo a loop electrosurgical excision procedure (LEEP). Which of the following represents the potential long-term complications from this procedure?
    A. Abscess and chronic pelvic inflammatory disease
    B. Cervical incompetence and cervical stenosis
    C. Constipation and fecal incontinence
    D. Hernia and intraperitoneal adhesions
    E. Urinary incontinence and urinary retention
    Explanation:
    The correct answer is
    B. The loop electrosurgical excision procedure (LEEP) is relatively simple and can be performed in the outpatient setting with local anesthesia. The procedure involves using a wire loop to excise lesions of the transformation zone. A benefit of LEEP, along with its ease of performance, is that it provides tissue that can be examined histologically. The most appropriate candidates for LEEP are women with high-grade squamous intraepithelial lesions (HGSIL). The immediate risks of LEEP are bleeding and infection. The possible long-term risks include cervical incompetence and cervical stenosis. These may seem like exact opposites, but LEEP can lead to both of them because, to a certain extent, it injures the cervix. If the body's response to this injury is with "too much" scarring, then cervical stenosis can result. If too much of the cervix is injured, the cervix may be too weakened to carry a pregnancy to term, and cervical incompetence may result. Abscess and chronic pelvic inflammatory disease (choice A) are not known to be long-term complications of the procedure. Constipation and fecal incontinence (choice C) should not be caused by LEEP. LEEP involves the distal portion of the cervix and should not involve the intestines or rectum at all. Hernia and intraperitoneal adhesions (choice D) should not result from LEEP. The procedure does not involve entry into the peritoneal cavity; therefore, there should be no risk of hernia or intraperitoneal adhesions. Urinary incontinence and urinary retention (choice E) are not known to be long-term complications from LEEP, as the procedure does not involve the bladder.
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    2) A 27-year-old woman, gravida 2, para 2, comes to the physician to have her staples removed after an elective repeat cesarean delivery. Her pregnancy course was uncomplicated. She states that she is doing well except that since the delivery she has noticed some episodes of sadness and tearfulness. She is eating and sleeping normally and has no strange thoughts or thoughts of hurting herself or others. Physical examination is within normal limits for a patient who is status post cesarean delivery. Which of the following is the most likely diagnosis?
    A. Maternity blues
    B. Postpartum depression
    C. Postpartum mania
    D. Postpartum psychosis
    E. Poststerilization depression
    Explanation:
    The correct answer is
    A. Maternity blues is the term used to describe a common postpartum reaction that occurs in 50 to 70% of postpartum patients. It is characterized by tearfulness, restlessness, and anxiety. Symptoms typically start in the first few days postpartum and resolve within 2 weeks. However, certain patients continue to have the symptoms for several weeks. Many symptoms may be seen in association with this disorder including headache, backache, fatigue, forgetfulness, insomnia, weeping, depression, anxiety, and negative feelings toward the newborn infant. Interestingly, another component of the syndrome may be episodes of elation, and such mood lability can be especially distressing for the new mother. It is unclear what the etiology of these symptoms is. Certainly, the postpartum period with a newborn can be stressful and life changing, which can certainly lead to mood changes and a number of emotional responses. Some researchers have argued that changes in hormone levels are at the root of the maternity blues, but this has never been definitively proven. This patient does not have evidence of a true postpartum depression (e.g., insomnia, lack of appetite, or anhedonia) or postpartum psychosis (e.g., bizarre thoughts) and she does not have any thoughts of hurting herself or her baby. Therefore, the most likely diagnosis is maternity blues and she should be given support and reassurance. The patient must also be cautioned, however, that if her symptoms do not resolve, or if they worsen, then she must call or return. Postpartum depression (choice B) is a depression that occurs in about 10% of postpartum women and it is more serious than the maternity blues. Symptoms may include sleep disturbances and changes in appetite. Postpartum mania (choice C) or postpartum psychosis (choice D) is a psychiatric disorder that occurs in about 1 per 1,000 deliveries. It is characterized by severe anxiety, agitation, disordered thoughts, and confusion. Hospitalization is required. Poststerilization depression (choice E) is a depression that is seen in women following a tubal ligation or other form of permanent sterilization. This patient did not have a sterilization procedure.
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    3) A 22-year-old primigravid woman comes to the labor and delivery ward at term with regular, painful contractions. Her prenatal course was unremarkable. She has a past medical history significant for mitral valve prolapse with regurgitation demonstrated on echocardiography. She takes no medications and has no allergies to medications. Examination shows that her cervix is 4 centimeters dilated and the fetus is in vertex presentation. The fetal heart rate is reassuring. Which of the following is the most appropriate management of this patient?
    A. Administer intravenous antibiotics throughout labor.
    B. Administer intravenous antibiotics 30 minutes prior to the delivery.
    C. Administer intravenous antibiotics after the cord is clamped.
    D. Administer intravenous antibiotics six hours after the delivery.
    E. Antibiotic prophylaxis is not necessary
    Explanation:
    The correct answer is
    E. Bacterial endocarditis is a potentially life-threatening infection that can develop in patients with structural cardiac disease who are exposed to bacteremia. The risk of developing endocarditis depends upon both the cardiac condition and the nature of the procedure. The American Heart Association periodically publishes guidelines for the prevention of bacterial endocarditis. According to the American Heart Association guidelines, antibiotic prophylaxis is not necessary for cesarean delivery or normal vaginal delivery. The possible exception to this is for patients with "high risk" cardiac conditions, which include women with a history of endocarditis, or who have prosthetic heart valves, complex cyanotic congenital heart disease, or surgically corrected systemic pulmonary shunts. Mitral valve prolapse if associated with mitral regurgitation (demonstrated by Doppler or a murmur) is considered a moderate risk condition and therefore antibiotic prophylaxis is not necessary. To administer intravenous antibiotics throughout labor (choice A), to administer intravenous antibiotics 30 minutes prior to the delivery (choice B), to administer intravenous antibiotics after the cord is clamped (choice C), or to administer intravenous antibiotics six hours after the delivery (choice D) would not be necessary. As explained above, mitral valve prolapse with regurgitation is considered to be a moderate risk condition and, for these conditions, antibiotic prophylaxis to prevent bacterial endocarditis is not necessary.
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    4) A 26-year-old primigravid woman at 42 weeks' gestation comes to the labor and delivery ward for induction of labor. The prenatal course was significant for a positive group B Streptococcus culture performed at 35 weeks. Antenatal testing over the past 2 weeks has been unremarkable. The patient is started on lactated Ringer's IV solution. Sterile vaginal examination shows that the patient's cervix is long, thick, and closed. Prostaglandin (PGE2) gel is placed into the vagina, and electronic fetal heart rate monitoring is continued. In approximately 60 minutes, the fetal heart rate falls to the 90s, as the tocodynamometer shows the uterus to be contracting every 1 minute with essentially no rest in between contractions. Which of the following was most likely the cause of the uterine hyperstimulation?
    A. Infection
    B. IV fluids
    C. Postdates pregnancy
    D. Prostaglandin (PGE2) gel
    E. Vaginal examination
    Explanation:
    The correct answer is
    D. Prostaglandin (PGE2) gel is widely used for labor induction. In simple terms, it is used "to soften" an unfavorable cervix, to make the cervix more favorable for induction. It has been shown to lead to an improvement in the Bishop's score, a shorter duration of labor, a need for lower maximal doses of oxytocin, and a reduced incidence of cesarean deliveries. PGE2 gel can also cause uterine contractions. One of the major side effects with PGE2 gel is uterine hyperstimulation. This occurs when uterine contractions come one right after the other, or when there is a tetanic contraction (a prolonged uterine contraction with no rest period). In this setting, the fetus can become hypoxic with a resultant bradycardia. This patient had the gel placed and 60 minutes later had uterine hyperstimulation. Infection (choice A) has not been shown to cause uterine hyperstimulation. This patient's group B Streptococcus colonization is likely noncontributory. IV fluids (choice B), unless oxytocin is present, do not cause uterine hyperstimulation. Postdates pregnancy (choice C) is the reason for this patient's induction and not likely the direct cause of her uterine hyperstimulation. Vaginal examination (choice E) does not usually cause uterine hyperstimulation. Vaginal examination with a cervical examination can be used for fetal scalp stimulation-rubbing the baby's head to provoke an acceleration of the fetal heart rate. However, this does not usually provoke uterine hyperstimulation.
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    5) A 16-year-old female comes to the physician because of an increased vaginal discharge. She developed this symptom 2 days ago. She also complains of dysuria. She is sexually active with one partner and uses condoms intermittently. Examination reveals some erythema of the cervix but is otherwise unremarkable. A urine culture is sent which comes back negative. Sexually transmitted disease testing is performed and the patient is found to have gonorrhea. While treating this patient's gonorrhea infection, treatment must also be given for which of the following?
    A. Bacterial vaginosis
    B. Chlamydia
    C. Herpes
    D. Syphilis
    E. Trichomoniasis
    Explanation:
    The correct answer is
    B. This patient has a gonorrhea infection. Gonorrhea is one of the most prevalent sexually transmitted diseases (STDs) in the United States. It is more common in patients of lower socioeconomic status, patients with multiple sexual partners, and in urban settings. The causative organism is N. gonorrhoeae, a gram-negative aerobic diplococcus. Up to 80% of women that are infected with the organism will have no symptoms at all or only vague symptoms. Symptoms that are frequently noted are vaginal discharge, postcoital spotting, and urinary symptoms if the urethra is involved. Examination may reveal a cervicitis, although this is not always present. A patient found to have gonorrhea should be treated with intramuscular ceftriaxone or oral cefixime, ofloxacin, or ciprofloxacin. These medications will effectively eradicate the gonococcus. However, because Chlamydia trachomatis can be isolated in up to 50% of women with gonorrhea and because women treated for gonorrhea only may soon go on to develop Chlamydia or pelvic inflammatory disease (PID), any woman receiving treatment for gonorrhea should also be treated for Chlamydia. Treatment of Chlamydia is with azithromycin or doxycycline. It is also essential that this patient's partner be treated as well. When treating a patient for gonorrhea, there is no need to treat the patient with metronidazole to treat bacterial vaginosis (choice A) as well, unless there is evidence of a bacterial vaginosis . Herpes (choice C) often presents as painful vesicles and ulcers. Patients with gonorrhea do not need to be treated for herpes as well, unless there is evidence for herpes infection. Patients with gonorrhea are at increased risk of having other sexually transmitted diseases, including syphilis (choice D). It would be prudent to check this patient for syphilis with a blood test. However, in the absence of a positive syphilis test, patients with gonorrhea do not need to be treated for syphilis. Trichomoniasis (choice E) is treated with metronidazole. Again, as with bacterial vaginosis, herpes, and syphilis, unless there is evidence of Trichomonas infection, the patient does not needed to be treated for trichomoniasis.
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    6) A 16-year-old nulligravid woman comes to the emergency department because of heavy vaginal bleeding. She states that she normally has heavy periods every month but missed a period last month and this period has been unusually heavy with the passage of large clots. She has no medical problems, has no history of bleeding difficulties, and takes no medications. Her temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, pulse is 96/minute and respirations are 12/minute. Pelvic examination shows a moderate amount of blood in the vagina, a closed cervix, and a normal uterus and adnexae. Hematocrit is 30%. Urine hCG is negative. Which of the following is the most appropriate management?
    A. Expectant management
    B. Hysteroscopy
    C. Oral contraceptive pills
    D. Laparoscopy
    E. Laparotomy
    Explanation:
    The correct answer is
    C. This patient has menorrhagia, likely due to an anovulatory cycle. During the first few years after menarche, it is common for women to have some anovulatory cycles and irregular menses. During an anovulatory cycle, because no egg is released and no corpus luteum is formed, there is no progesterone production. This lack of progesterone means that the endometrium is stimulated by unopposed estrogen. This leads to a buildup of the endometrial lining and often, when the period does come, menorrhagia. The treatment for this type of bleeding is with oral contraceptive pills. The pills, by providing estrogen and progesterone, can help to stabilize the endometrium and halt the bleeding. Because this patient is bleeding heavily and now has a significant hematocrit drop (30%), it is reasonable to provide high doses of hormones. A common method of doing this is to have the patient take three pills per day for three days, followed by 2 pills per day for three days, followed by one pill per day until the pack is finished. It is important in this case to note that pregnancy was ruled out with a negative urine hCG test. It is essential to rule out pregnancy in a young woman who presents with bleeding from the vagina. Expectant management (choice A) would not be appropriate. This patient is losing enough blood to have dropped her hematocrit to 30%. If one does not intervene, there is the risk that the patient will continue to bleed and to drop her hematocrit even further. Patients with dysfunctional uterine bleeding such as this can lose enough blood to require a blood transfusion with the corresponding risks (e.g. infection and transfusion reaction.) Hysteroscopy (choice B) would not be the most appropriate option. With such severe vaginal bleeding, hysteroscopy will likely not provide sufficient visualization of the endometrium. Also, hysteroscopy exposes the patient to the risks of surgery (e.g. perforation of the uterus, damage to internal organs) for a problem that can be managed effectively medically. Laparoscopy (choice D) and laparotomy (choice E) would not be appropriate. This patient is having uterine bleeding that is most likely coming from inside the uterus (i.e. the endometrial lining). Laparoscopy and laparotomy will provide a view of only the exterior of the uterus (the serosal surface) and thus will not be an effective approach to this problem.
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    7) A 12-year-old female comes to the physician because of a vaginal discharge. The discharge started about 2 months ago and is whitish in color. There is no odor. The patient has no complaints of itching, burning, or pain. The patient started breast development at 9 years of age and her pubertal development has proceeded normally to this point. She has not had her first menses and she is not sexually active. She has no medical problems. Examination is normal for a 12-year-old female. Microscopic examination of the discharge shows no evidence of pseudohyphae, clue cells, or trichomonads. Which of the following is the most likely diagnosis?
    A. Bacterial vaginosis
    B. Candida vulvovaginitis
    C. Physiologic leukorrhea
    D. Syphilis
    E. Trichomoniasis
    Explanation:
    The correct answer is
    C. Physiologic leukorrhea can be seen during 2 different periods of childhood. Some female neonates develop a physiologic leukorrhea shortly after birth as maternal circulating estrogens stimulate the newborn's endocervical glands and vaginal epithelium. The discharge in these neonates is often gray and gelatinous. Physiologic leukorrhea can also be seen during the months preceding menarche. During this time, rising estrogen levels lead to a whitish discharge not associated with any symptoms of irritation. This patient has a whitish discharge, no other symptoms, and she has had normal pubertal development up to this point. The discharge itself has no characteristics of infection. Therefore, physiologic leukorrhea is the most likely diagnosis. Bacterial vaginosis (choice A) is not the most likely diagnosis in this patient because the discharge is not malodorous and there are no clue cells seen on microscopic examination of the discharge. Candida vulvovaginitis (choice B) is not the most likely diagnosis because the discharge is not thick and white (or "cottage-cheese"-like) and the patient has no irritative symptomatology. Syphilis (choice D) most often presents with a painless ulcer (called a chancre) or is found with serologic testing. A nonmalodorous, whitish vaginal discharge in a 12-year-old female who is not sexually active is almost certainly not evidence of syphilis. Trichomoniasis (choice E) is also highly unlikely in this patient and the lack of trichomonads on the microscopic examination effectively rules out this diagnosis.
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    8) A 34-year-old woman comes the physician because of lower abdominal cramping. The cramping started 2 days ago. Examination is unremarkable except for a pelvic examination that reveals a 10-week sized uterus. Urine hCG is positive, and pelvic ultrasound reveals a 10-week intrauterine pregnancy with a fetal heart rate of 160. The patient states that she is not sure whether to keep the pregnancy. Which of the following is the most appropriate next step in management?
    A. Counsel the patient or refer to an appropriate counselor
    B. Notify the patient's parents
    C. Notify the patient's partner
    D. Schedule a termination of pregnancy
    E. Tell the patient that she is likely to have a miscarriage
    Explanation:
    The correct answer is
    A. The decision of whether to have a termination of pregnancy is a deeply personal one. This patient has just been notified that she is pregnant with a 10-week fetus. She is unsure whether she wants to keep her pregnancy or terminate it. In this setting, the most appropriate next step is to counsel the patient regarding her options or refer the patient for counseling. In a balanced way, the patient should be fully informed of all of her options including raising the child herself, placing the child up for adoption, and abortion. To notify the patient's parents (choice B) is not appropriate. Such an act would violate the patient's confidentiality. A 34-year-old woman is an adult and issues of parental notification do not apply. To notify the patient's partner (choice C) is not appropriate. This notification would also violate confidentiality. To schedule a termination of pregnancy (choice D) would not be appropriate. This patient has just informed the physician that she is unsure what she wants to do. To just go ahead and schedule the termination without proper counseling of the patient would not be a balanced or proper approach for the patient. To tell the patient that she is likely to have a miscarriage (choice E) is inappropriate. This patient may have a miscarriage, as might any patient with a first-trimester pregnancy. However, once an intrauterine pregnancy with fetal cardiac activity is identified, the risk of miscarriage is approximately 10%. Therefore, she is most likely not to have a miscarriage.
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    9) A 29-year-old woman comes to the physician for follow-up of a right breast lump. The patient first noticed the lump 4 months ago. It was aspirated at that time, and cytology was negative, but the cyst recurred about 1 month later. The cyst was re-aspirated 2 months ago and, again, the cytology was negative. The lump has recurred. Examination reveals a mass at 10 o'clock, approximately 4 cm from the areola. Ultrasound demonstrates a cystic lesion. Which of the following is the most appropriate next step in management?
    A. Mammography in 1 year
    B. Ultrasound in 1 year
    C. Tamoxifen therapy
    D. Open biopsy
    E. Mastectomy
    Explanation:
    The correct answer is
    D. Breast lumps are a common complaint in women. Many of these masses are benign processes. Benign conditions of the breast include fibrocystic disease, fibroadenomas, galactoceles, abscesses, and necrosis. It is appropriate to aspirate a palpable macrocyst in the breast; the fluid should be placed on a slide and sent for cytologic evaluation. If the cytology is negative, no further treatment is needed. Some would argue that if the cyst recurs, it may be aspirated again. However, when a lesion recurs twice, as has occurred in this patient, open biopsy is warranted. To wait to perform mammography in 1 year (choice A) or ultrasound in 1 year (choice B) would be incorrect management. First, if a malignancy is present, waiting another year will allow progression of the cancer. Second, the mammogram is not definitive. Imaging can contribute information to the workup of a breast mass, but the definitive diagnosis rests on histologic evaluation. Tamoxifen therapy (choice C) is used to both prevent and treat breast cancer. However, this patient does not yet have a diagnosis. She has a cystic mass that has been aspirated twice and has recurred twice. She therefore requires a biopsy to establish a diagnosis prior to the institution of any treatment. Mastectomy (choice E) would not be indicated for this patient. Again, this patient does not have a diagnosis, and to perform a mastectomy for a recurrent cyst would be inappropriate.
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    10) A 27-year-old primigravid woman at 39 weeks' gestation comes to the labor and delivery ward with a gush of fluid and regular contractions. Examination shows that she is grossly ruptured, contracting every 2 minutes, and that her cervix is dilated to 4 cm. The fetal heart rate tracing is in the 140s and reactive. She is admitted to labor and delivery, and over the following 4 hours she progresses to 9 cm dilation. Over the past hour, the fetal heart rate has increased from a baseline of 140 to a baseline of 160. Furthermore, moderate to severe variable decelerations are seen with each contraction. The fetal heart rate does not respond to scalp stimulation. The decision is made to proceed with cesarean delivery. Which of the following is the reason for the cesarean delivery and the preoperative diagnosis?
    A. Fetal acidemia
    B. Fetal distress
    C. Fetal hypoxic encephalopathy
    D. Low neonatal APGAR scores
    E. Non-reassuring fetal heart rate tracing
    Explanation:
    The correct answer is
    E. Labor and delivery represents a process of stress for the fetus. With each uterine contraction, blood flow to the placenta decreases, and the fetus is exposed to transient hypoxia. As the labor progresses and more and more contractions occur, this hypoxia can eventually lead to a change from aerobic to anaerobic metabolism. This change can lead to a buildup of acid in the fetus, or fetal acidemia. However, most fetuses tolerate the stress of labor and delivery just fine. The fetus has a variety of protective mechanisms, including a blood buffering system and the diving reflex (a lowering of the heart rate in times of hypoxic stress), to protect it from becoming dangerously acidemic. Electronic fetal monitoring is used to determine whether the fetus is becoming dangerously acidemic or "stressed" during labor so that delivery can occur prior to hypoxic damage to organs. Unfortunately, electronic fetal monitoring is not a very specific tool for identifying fetal acidemia. Many fetuses with a non-reassuring fetal heart rate tracing do not have acidemia and are not in distress. However, it can be very difficult to distinguish non-acidemic fetuses with non-reassuring fetal heart rate tracings from acidemic fetuses with non-reassuring fetal heart rate tracings. Thus, the delivery of many fetuses is expedited because of the concern for fetal acidemia when, in fact, the fetus is not acidemic at all. Thus, it is most accurate to state, as is in this case, that the fetus was delivered because of the non-reassuring fetal heart rate tracing. Fetal acidemia (choice A) is not the reason for delivery. In fact, there is a strong likelihood that this fetus is not acidemic at all. Fetal distress (choice B) is not the reason for delivery. There is a strong likelihood that this fetus is perfectly healthy and will have high neonatal APGAR scores and no distress at all. Fetal hypoxic encephalopathy (choice C) is not the reason for delivery. The desire to prevent hypoxic/acidemic damage to organs, including the brain, is the reason for expediting delivery. However, the non-reassuring fetal tracing does not indicate that hypoxic encephalopathy is necessarily occurring. Low neonatal APGAR scores (choice D) can be a marker of fetal acidemia. However, many fetuses with non-reassuring fetal heart rate tracings do not have low neonatal APGAR scores.
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    11) A 29-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the labor and delivery ward with frequent painful contractions. Her prenatal course was significant for a urine culture that showed 100,000 colony-forming units/milliliter of Group-B streptococci and asthma, for which she uses an albuterol inhaler. Examination shows that she is contracting every 2 minutes and her cervix is 5 centimeters dilated and 100% effaced. Which of the following medications should this patient be treated with during labor and delivery?
    A. Betamethasone
    B. Folic acid
    C. Magnesium sulfate
    D. Oxytocin
    E. Penicillin
    Explanation:
    The correct answer is
    E. The Group B Streptococcus (GBS) is a bacterium that is a part of the normal bacterial colonization of many women. During pregnancy, as many as 20-40% of women will be colonized with GBS. Most babies born to colonized mothers will not develop infection with GBS. However, approximately 1 to 4 % of neonates will develop infection. The likelihood of infection is increased if the mother has preterm labor and delivery (< 37 weeks), prolonged rupture of the membranes (>18 hours), or intrapartum temperature greater than 38.0 C (100.4 F). Two primary methods are used to determine which women will receive antibiotics during labor. The first method is based upon risk factors. The five risk factors are: 1. History of a GBS-affected neonate. 2. Urine culture with GBS. 3. Preterm labor (<37 weeks). 4. Membranes ruptured for greater than eighteen hours in labor. 5. Temperature greater than 38.0 C (100.4 F) in labor. A woman with any one of these five risk factors should receive antibiotics in labor. The second method is based on screening, with pregnant women being screened for GBS at 35 to 37 weeks with a culture of the vagina, perineum, and anus. Women should be screened only if they do not have a history of a GBS-affected neonate or GBS bacteriuria. This patient has GBS bacteriuria; therefore, she did not undergo screening. She should be treated with penicillin during labor and delivery. Betamethasone (choice A) is a corticosteroid that is given to women to accelerate fetal maturity to help prevent neonatal respiratory distress syndrome and other sequelae of prematurity. This patient is at 38 weeks' gestation and, therefore, does not require betamethasone. Folic acid (choice B) is a supplement that women should take preconceptionally and during pregnancy (not during labor and delivery) to help prevent neural tube defects. Magnesium sulfate (choice C) is used in obstetrics to prevent preterm labor and for seizure prophylaxis. This patient does not have preterm labor and does not have preeclampsia. Oxytocin (choice D) is given to women to induce or to augment labor. This patient, however, appears not to need oxytocin as she is contracting every 5 minutes and progressing in labor.
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    12) A 31-year-old primigravid woman comes to the physician for a prenatal visit. She is known to be HIV positive. She also has asthma, for which she uses an inhaler. She had a diagnostic laparoscopy at age 20 for pelvic pain and has had no other surgeries. She has no known drug allergies. Extensive counseling is given to the patient regarding vertical transmission of HIV to the fetus. It is recommended to her that she take antiretroviral therapy during the pregnancy to decrease the vertical transmission rate. It is also recommended to her that she have a scheduled cesarean delivery. After consideration of these options, the patient chooses not to take the antiretrovirals and opts for a vaginal delivery. Which of the following represents the approximate risk of vertical transmission (from the mother to the fetus) for this patient?
    A. 2%
    B. 8%
    C. 25%
    D. 50%
    E. 100%
    Explanation:
    The correct answer is
    C. Studies have demonstrated that in the absence of maternal treatment with antiretroviral therapy or scheduled cesarean delivery, the rate of vertical transmission is approximately 25%. Thus, all pregnant women should be offered HIV testing to identify those patients who are infected so that they may receive antiretroviral therapy and be offered scheduled cesarean delivery to decrease the rate of vertical transmission. 2% (choice A) represents the approximate rate of vertical transmission in women who receive antiretroviral therapy during the pregnancy and a scheduled cesarean delivery (i.e., a cesarean delivery prior to the onset of labor or rupture of membranes.) 8% (choice B) represents the approximate rate of vertical transmission when women are treated with antiretroviral therapy during pregnancy and the neonate is treated postpartum. This rate was identified in the landmark study from the Pediatric AIDS Clinical Trials Group 076 study. This study showed that antepartum, intrapartum, and postpartum zidovudine (ZDV) use would reduce the vertical transmission rate from 25% to 8%. 50% (choice D) and 100% (choice E) are incorrect.
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    13) A 22-year-old woman, gravida 4, para 3, at 38 weeks' gestation comes to the labor and delivery ward with a gush of fluid. Sterile speculum examination reveals a pool of fluid that is nitrazine positive and forms ferns when viewed under the microscope. The fetal heart rate is in the 150s and reactive. An ultrasound demonstrates that the fetus is in the breech position. A cesarean delivery is performed. During the operation, the physician, who has received no recent immunizations, is stuck with a needle that had been used on the patient. Which of the following is this physician at greatest risk of contracting?
    A. HIV
    B. Hepatitis B
    C. Hepatitis C
    D. Scabies
    E. Syphilis
    Explanation:
    The correct answer is
    B. Studies have shown that surgeons can readily acquire hepatitis B virus from patients. The risk of acquiring hepatitis B is significantly higher than the risk for HIV, and somewhat higher than the risk for hepatitis
    C. Thus, it is essential that health care workers be immunized against the hepatitis B virus. The immunization schedule is for administration of the vaccine at 1, 2, and 6 months. The Centers for Disease Control and Prevention recommends that postvaccination testing for antibodies be performed to identify an adequate response to the immunization. Individuals who do not demonstrate the formation of antibodies after the immunizations are given should be tested for hepatitis B surface antigen to ensure that they haven't already been infected. With immunization, the risk of acquiring hepatitis B from a needle stick injury is significantly lessened. HIV (choice A) can be transmitted through needle-stick injury. However, the risk of this transmission is less than that of hepatitis B in individuals who have not been immunized. Hepatitis C (choice C) appears to be more transmissible through needle-stick injury than HIV, but less transmissible than hepatitis
    B. However, because there is no immunization for hepatitis C available yet, and because the infection is so widespread in the population, the risk of transmission is of grave concern. Scabies (choice D) is a skin parasite that is transmitted through physical contact. Syphilis (choice E) is a sexually transmitted disease that is most often transmitted through sexual contact. Transmission through needle-stick injury is not a primary route.
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    14) A 43-year-old African American woman comes to the physician because of her concern regarding breast cancer. She has no complaints at present. In past years, she had noted bilateral breast tenderness prior to her menses, but this has since abated. She has no medical problems. She had two cesarean deliveries, but no other surgeries. She takes a low-dose oral contraceptive pill and has no known drug allergies. She does not smoke, and her family history is negative. Physical examination is normal. All mammograms (yearly since age 40) have been negative to date. She wants to know whether BRCA1 and BRCA2 screening would be appropriate for her. Which of the following is the correct response?
    A. BRCA1 and 2 screening is not recommended
    B. BRCA1 and 2 screening should be performed after age 50
    C. BRCA1 and 2 screening should be performed if breast pain recurs
    D. BRCA1 screening is recommended
    E. BRCA2 screening is recommended
    Explanation:
    The correct answer is
    A. Of the cases of breast cancer that are heritable, approximately 80% are due to mutations in BRCA1 and BRCA2. BRCA1 is associated with high risk for breast and ovarian cancer. BRCA2 is associated with a high risk of female and male breast cancer. On the basis of our current understanding, however, less than 10% of all breast cancer cases can be considered to be heritable. Therefore, the total number of breast cancer cases associated with BRCA1 and BRCA2 mutations is a small percentage of the total number of breast cancer cases. Furthermore, there are numerous mutations that can occur in the BRCA1 and BRCA2 genes and can be related to an increased cancer risk. Some patients who have a mutation associated with cancer will not go on to develop cancer. Other patients may have a strong family history of breast cancer but no identifiable mutation. At present, therefore, screening of the general population is not recommended. This patient has no family history and is not in a high-risk group. Her prior breast tenderness was likely mastalgia related to the premenstrual phase. Therefore, BRCA1 and 2 screening would not be recommended for this patient. To state that BRCA1 and 2 screening should be performed after age 50 (choice B) is incorrect. As noted above, given the limitations of the testing for BRCA1 and 2 mutations, screening of the general population is not recommended. To state that BRCA1 and 2 screening should be performed if breast pain recurs (choice C) is incorrect. This patient does not need screening, not because her breast pain has resolved, but rather because BRCA1 and 2 screening is not appropriate for the general population at this time. As noted above, her breast pain was likely cyclic mastalgia secondary to hormonal changes prior to menses. To state that either BRCA1 screening (choice D) or BRCA2 screening (choice E) is recommended is not correct. As explained above, screening for neither of these is recommended.
    --------------------------------------------------------------------------------
    15) A 32-year-old woman comes to the hospital for an elective repeat cesarean delivery. Four years ago she had a primary cesarean delivery for a nonreassuring fetal heart rate tracing. Two years ago she chose to have an elective repeat cesarean delivery rather than attempt a vaginal birth after cesarean (VBAC). Her prenatal course was uncomplicated except that she has mitral valve prolapse. An echocardiograph demonstrated the mitral valve prolapse, but no other structural cardiac disease. Which of the following is the correct management of this patient?
    A. Administer intravenous antibiotics 30 minutes prior to the procedure
    B. Administer intravenous antibiotics immediately after the procedure
    C. Administer intravenous antibiotics for 24 hours after the procedure
    D. Administer oral antibiotics 6 hours after the procedure
    E. No antibiotics are needed
    Explanation:
    The correct answer is
    E. Mitral valve prolapse affects approximately 5% of women of childbearing age. Consequently, the issue of mitral valve prolapse and the need for antibiotics comes up quite often in obstetrics, particularly with delivery (either vaginal delivery or cesarean delivery). Bacterial endocarditis is a life-threatening infection that can develop in patients with structural cardiac disease who are exposed to bacteremia. The risk for any given procedure depends upon the nature of the procedure itself and on the nature of the cardiac lesion. Periodically, the American Heart Association publishes guidelines for the prevention of bacterial endocarditis. According to the American Heart Association guidelines, antibiotic prophylaxis is not necessary for cesarean delivery or normal vaginal delivery. The possible exception to this is for patients with "high risk" cardiac conditions, which includes women with a history of endocarditis or who have prosthetic heart valves, complex cyanotic congenital heart disease, or surgically corrected systemic pulmonary shunts. Mitral valve prolapse, if associated with mitral regurgitation (demonstrated by Doppler or a murmur), is considered a moderate risk condition and, therefore, antibiotic prophylaxis is not necessary. This patient, therefore, does not require antibiotics prior to, during, or after her cesarean delivery. To administer intravenous antibiotics 30 minutes prior to the procedure (choice A), immediately after the procedure (choice B), 24 hours after the procedure (choice C), or to administer oral antibiotics 6 hours after the procedure (choice D) would all be unnecessary. As explained above, the reason for administering antibiotics to women with structural cardiac disease is to prevent bacterial endocarditis. Bacterial endocarditis is a potentially fatal condition. However, there are different degrees of structural cardiac disease. Mitral valve prolapse with regurgitation is considered to be a moderate risk condition. The American Heart Association does not recommend endocarditis prophylaxis for women with moderate risk conditions undergoing vaginal or cesarean delivery.
    --------------------------------------------------------------------------------
    16) A 38-year-old woman, gravida 4, para 4, comes to the physician 8 days after a cesarean delivery complaining of redness and pain at the leftmost aspect of her incision. Her cesarean delivery was performed secondary to a non-reassuring fetal heart rate tracing. She was feeling well after the operation until 4 days ago, when she developed pain and redness around her incision. Her temperature is 37 C (98.6 F), blood pressure is 118/78 mm Hg, pulse is 88/min, and respirations are 12/min. There is marked erythema and induration around the incision. At the left margin of the incision there is a fluctuant mass. Which of the following is most appropriate next step in management?
    A. Expectant management
    B. Oral antibiotics only
    C. IV antibiotics only
    D. Incision and drainage
    E. Laparotomy
    Explanation:
    The correct answer is
    D. This patient most likely has a wound abscess. When antibiotic prophylaxis is used, wound infections occur at a rate of approximately 1% after cesarean deliveries. However, this patient appears to have more than a cellulitis. The fluctuant mass at the leftmost aspect of the incision is highly likely to be an abscess. The proper treatment for a wound abscess is with incision and drainage. This patient is unlikely to improve with expectant management (choice A). An abscess almost always requires incision and drainage for cure. Expectant management may lead to worsening of the infection, with the possibility of spread to adjacent structures (e.g., fascia) or to bacteremia and sepsis. Oral antibiotics only (choice B) or IV antibiotics only (choice C) may not resolve the abscess. Antibiotics often do not penetrate the abscess cavity. Laparotomy (choice E) is probably not necessary for this patient. She has a wound abscess that should be addressed with incision and drainage. In the process of the incision and drainage, the fascia should be checked to ensure that it is intact. As long as the fascia is intact and there is no intra-abdominal process, there is no need for laparotomy.
    --------------------------------------------------------------------------------
    17) A 39-year-old woman, gravida 3, para 2, at term comes to the labor and delivery ward complaining of a gush of fluid. Examination shows her to be grossly ruptured, and ultrasound reveals that the fetus is in vertex presentation. The fetal heart rate is in the 120s and reactive. After a few hours, with no contractions present, oxytocin is started. Three hours later, the tocodynamometer shows the patient to be having contractions every minute and lasting for approximately 1 minute with almost no rest in between contractions. The fetal heart rate changes from 120s and reactive to a bradycardia to the 80s. Sterile vaginal examination shows that the cervix is 6 cm dilated. Which of the following is the most appropriate next step in management?
    A. Discontinue oxytocin
    B. Start magnesium sulfate
    C. Perform forceps assisted vaginal delivery
    D. Perform vacuum assisted vaginal delivery
    E. Perform cesarean delivery
    Explanation:
    The correct answer is
    A. This patient has the findings most consistent with uterine hyperstimulation-more than 5 contractions in 10 minutes, contractions lasting 2 minutes or more, or contractions of normal duration occurring within 1 minute of each other and a non-reassuring fetal heart rate tracing. Oxytocin is one of the most frequently used medications in the U.S. It is very effective at producing contractions and used very often for induction of labor. The most common adverse effect with oxytocin is a non-reassuring fetal heart rate pattern brought about by uterine hyperstimulation. Because it has a very short half-life (3-5 minutes), discontinuing the oxytocin often resolves the hyperstimulation quickly. In this patient, with a bradycardia to the 80s, this step is most appropriate. In situations where the fetal heart rate tracing is not as non-reassuring, the oxytocin dosage may be reduced rather than discontinued completely. If uterine hyperstimulation induced by oxytocin does not respond to shutting the oxytocin off, one can start magnesium sulfate (choice B) or give terbutaline. Both of these may be given intravenously to treat uterine hyperstimulation that does not respond to other measures. To perform forceps-assisted (choice C) or vacuum-assisted (choice D) vaginal delivery would be contraindicated. This patient's cervix is only 6 cm dilated. Forceps and vacuum are not used unless the cervix is fully dilated. To perform a cesarean delivery (choice E) would not be appropriate prior to trying other steps. This fetus most likely is not suffering a metabolic acidemia, based on the fact that its reassuring heart rate tracing is in the 120s and reactive. Its bradycardia is directly related to the hyperstimulation, which is caused by the oxytocin. Thus, efforts should be made to manage the fetal distress with conservative measures prior to resorting to cesarean delivery.
    --------------------------------------------------------------------------------
    18) A 28-year-old primigravid woman at term comes to the labor and delivery ward with a gush of fluid and regular contractions. Her prenatal course was remarkable for her being Rh negative and antibody negative. Her husband is Rh positive. Over the following 10 hours, she progresses in labor and delivers a 3600-g boy via a normal spontaneous vaginal delivery. The placenta does not deliver spontaneously, and a manual removal is required. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send?
    A. Complete blood count
    B. Kleihauer-Betke
    C. Liver function tests
    D. Prothrombin time
    E. Serum potassium
    Explanation:
    The correct answer is
    B. Women who are Rh negative are at risk for developing Rh isoimmunization. Rh isoimmunization occurs when an Rh-negative mother becomes exposed to the Rh antigen on the red blood cells of an Rh-positive fetus. This exposure may lead the mother's immune system to become sensitized to the Rh antigen such that in a future pregnancy with an Rh-positive fetus, the mother's immune system may "attack" the Rh antigen on the fetal red blood cells. This immune response may lead to the development of fetal anemia, hydrops, and death. To prevent Rh isoimmunization from occurring, Rh-negative women who are not Rh alloimmunized should receive RhoGAM (anti-D immune globulin) at 28 weeks' gestation, within 72 hours after the birth of an Rh-positive infant, after a spontaneous abortion, or after invasive procedures such as amniocentesis. RhoGAM should also be strongly considered in cases of threatened abortion, antenatal bleeding, external cephalic version, or abdominal trauma. The amount that is usually given after the delivery of an Rh-positive fetus is 300 g. This amount is sufficient to cover a fetal to maternal hemorrhage of 30 mL (or 15 mL of fetal cells). However, some women will have a fetal to maternal hemorrhage that is in excess of this 30 mL-especially in cases such as manual removal of the placenta (like this patient had) or placental abruption. To determine the amount of fetal to maternal hemorrhage that occurred, it is necessary to perform a Kleihauer-Betke test. This acid-dilution procedure allows fetal red blood cells to be identified and counted. Knowing the amount of fetal to maternal hemorrhage that took place allows the correct amount of RhoGAM to be given. A complete blood count (choice A) will demonstrate the amount of maternal hemorrhage, but not the amount of fetal to maternal hemorrhage. Liver function tests (choice C), prothrombin time (choice D), and serum potassium (choice E) do not allow for the determination of the amount of fetal to maternal hemorrhage.
    --------------------------------------------------------------------------------
    19) A 22-year-old primigravid woman at term comes to the labor and delivery ward because of painful contractions every 2 minutes. She has had no gush of fluid and no bleeding from the vagina. Her prenatal course was unremarkable. She takes no medications and has no allergies to medications. Examination shows that her cervix is 6 cm dilated and 100% effaced; the fetus is at 0 station. The fetal heart rate has a baseline in the 150s and is reactive. The patient desires an epidural for pain relief. Which of the following should be given orally shortly before the epidural is placed?
    A. Antacid
    B. Antibiotic
    C. Aspirin
    D. Clear liquid meal
    E. Regular "house" meal
    Explanation:
    The correct answer is
    A. Aspiration pneumonitis is a major cause of anesthesia-related death in obstetrics. Most often, these aspiration events occur with the use of general anesthesia. Pregnant patients are at greater risk for aspiration because of the delayed gastric emptying that occurs during pregnancy and labor. Pregnancy is associated with increased levels of progesterone and displacement of the pylorus by the pregnant uterus. Labor is associated with pain and stress. All of these factors lead to delayed gastric emptying. Aspiration pneumonitis is caused by acidic gastric juices entering the lungs and inducing a sometimes-lethal chemical pneumonitis. When epidural anesthesia is administered, there is a risk of complications, including the development of total spinal anesthesia. The treatment for this complication is positive-pressure ventilation with 100% oxygen administered through an endotracheal tube. Therefore, when an epidural is going to be placed, the patient should be given an antacid (often 30 mL of 0.3 mL/L sodium citrate with citric acid, called Bicitra) to increase the stomach pH. This will help to prevent aspiration pneumonitis should an aspiration event take place during the administration of general anesthesia. It is not necessary to give an antibiotic (choice B) prior to the administration of an epidural. Antibiotics are used during labor for the prevention of group B Streptococcus sepsis, for patients with chorioamnionitis, for patients in need of valve or endocarditis prophylaxis, or during cesarean delivery for the prevention of infection. Aspirin (choice C) is not given prior to the placement of an epidural. A clear liquid meal (choice D) or a regular "house" meal (choice E) should not be given to patients prior to the placement of an epidural. Intake of food or liquids during labor places the patient at greater risk of aspiration pneumonitis. Patients in labor should be allowed small sips of water or ice chips.
    --------------------------------------------------------------------------------
    20) A 39-year-old woman, gravida 4, para 3, comes to the physician for a prenatal visit. Her last menstrual period was 8 weeks ago. She has had no abdominal pain or vaginal bleeding. She has no medical problems. Examination is unremarkable except for an 8-week sized, nontender uterus. Prenatal labs are sent. The rapid plasma reagin (RPR) test comes back as positive and a confirmatory microhemagglutination assay for antibodies to Treponema pallidum (MHA-TP) test also comes back as positive. Which of the following is the most appropriate pharmacotherapy?
    A. Erythromycin
    B. Levofloxacin
    C. Metronidazole
    D. Penicillin
    E. Tetracycline
    Explanation:
    The correct answer is
    D. This patient has syphilis. Syphilis is a disease caused by Treponema pallidum, a spirochete. A painless ulcer, called a chancre, typically found on the vagina or cervix, characterizes primary syphilis. If primary syphilis is untreated it can progress to secondary syphilis, which is characterized by "moth-eaten" alopecia, a maculopapular skin rash involving the palms and soles, and white patches on the tongue. Gumma formation, cardiac lesions, and central nervous system abnormalities characterize tertiary syphilis. Syphilis in pregnancy is associated with increased rates of preterm delivery, intrauterine growth retardation, and fetal demise. However, the most devastating complication of syphilis in pregnancy is congenital infection. Congenital infection of the fetus can lead to severe fetal morbidity and mortality. The key to preventing congenital infection of the fetus is adequate treatment of the mother. Therefore, every woman should be tested for syphilis during routine prenatal care. The RPR test and Venereal Disease Research Laboratory (VDRL) are screening tests for syphilis and are not entirely specific for Treponema pallidum infection. Certain other conditions, such as autoimmune syndromes and pregnancy itself, can give a falsely positive RPR test. Therefore, the RPR test should be followed up with a test that is specific for syphilis, such as the MHA-TP test. When both of these tests are positive and there is no history of syphilis infection and treatment, then the patient should be treated with intramuscular penicillin. Erythromycin (choice A) is recommended by some as the first-line treatment for chlamydia in pregnancy (others recommend azithromycin). Erythromycin is not the drug of choice for syphilis in pregnancy. Levofloxacin (choice B) and the other fluoroquinolones are considered contraindicated in pregnancy because of an association with musculoskeletal congenital anomalies. Metronidazole (choice C) is used during pregnancy for the treatment of bacterial vaginosis and trichomoniasis. It is not used for treatment of syphilis. Tetracycline (choice E) is contraindicated during pregnancy because of effects on fetal bones and teeth.
    --------------------------------------------------------------------------------
    21) A 67-year-old woman comes to the physician because of pain with urination and frequent urination. She has hypertension for which she takes a beta-blocker, but no other medical problems. She states that she is not sexually active. She does not smoke and drinks cranberry juice daily. Examination shows mild suprapubic tenderness and genital atrophy but is otherwise unremarkable. Urinalysis shows 50 to 100 leukocytes/high powered field (hpf) and 5 to 10 erythrocytes/hpf. Which of the following is the most likely cause of the infection?
    A. Cardiac disease
    B. Cranberry juice ingestion
    C. Hypoestrogenism
    D. Nephrolithiasis
    E. Sexual intercourse
    Explanation:
    The correct answer is
    C. This patient has a presentation that is most consistent with urinary tract infection (UTI). Two of the major risk factors for uncomplicated UTI are sexual intercourse and hypoestrogenism. Sexual intercourse is believed to lead to urinary tract infection by introducing colonizing bacteria into the bladder. Sexual intercourse has been shown to increase the number of bacteria in the urine up to ten times. Hypoestrogenism is believed to be a risk factor for UTI because it is known that postmenopausal women not receiving estrogen replacement therapy (ERT) are at greater risk for developing a UTI compared with those women who do use ERT. Furthermore, estrogen administration has been shown to prevent recurrent infection. Cardiac disease (choice A) is a major risk factor for a number of conditions. However, cardiac disease is not a known risk factor for UTI. Cranberry juice ingestion (choice B) has, for many years, been believed to help prevent UTIs. Many in the medical establishment viewed this as an "old wives tale." However, there have been many studies that have shown that cranberry juice contains substances that inhibit bacterial adherence. Moreover, a recent study showed that elderly women that drank cranberry juice have lower rates of pyuria and bacteriuria and a decreased need for antibiotics. Nephrolithiasis (choice D) can be a risk factor for the development of an eventual infection, but it is not as common a risk factor as is hypoestrogenism or sexual intercourse. Furthermore, this patient has no evidence of nephrolithiasis, which typically causes severe to excruciating episodes of pain. Sexual intercourse (choice E), as noted above, is a well-known risk factor for the development of a UTI. Sexually active women with recurrent UTIs may be treated with a single dose of antibiotic prophylactically after intercourse. This patient, however, has stated that she is not sexually active.
    --------------------------------------------------------------------------------
    22) A 39-year-old woman, gravida 2, para 1, at 30-weeks gestation comes to the physician for a prenatal visit. The patient's due date was determined by a 7-week ultrasound. Her prenatal course has been unremarkable. She has no complaints of contractions, loss of fluid, or bleeding from the vagina, and her baby is moving well. Examination demonstrates a fetal heart rate of 150 and a fundal height of 27 centimeters, which is the same measurement as that determined 4 weeks ago. This patient's fundal height measurement is most suggestive of which of the following?
    A. Inaccurate estimated date of delivery (due date)
    B. Intrauterine growth restriction
    C. Premature labor
    D. Twin gestation
    E. Uterine cancer
    Explanation:
    The correct answer is
    B. Fundal height measurement is a portion of the physical examination that should be performed routinely during prenatal care. It is performed by placing a measuring tape on the pubic symphysis and measuring to the top of the fundus. Between the gestational ages of 18 to 34 weeks, there is a rough correlation between weeks of gestation and fundal height in centimeters. For example, a woman at 26 weeks' gestation should have a fundal height that is roughly 26 centimeters. This patient is at 30 weeks' gestation and has a fundal height of 27 centimeters. Furthermore, and perhaps more importantly, there has been no change in the fundal height over the past four weeks. These findings are concerning for intrauterine growth restriction (IUGR). IUGR is a disorder in which the fetus is not growing appropriately. It is most commonly defined as an estimated fetal weight less than the 10th percentile for a given gestational age. Given that this patient's fundal height does not appear to have increased over the past 4 weeks and that it is 3 centimeters less than expected, IUGR is of concern and this patient should be sent for an ultrasound to evaluate fetal size. This patient is unlikely to have an inaccurate estimated date of delivery (due date) (choice A) because her due date was determined by a 7-week ultrasound. Ultrasound dating of a pregnancy is more accurate the earlier in pregnancy that it is performed and a 7-week ultrasound is considered excellent for establishing a due date. Premature labor (choice C) would not be a concern in this patient with no contractions and no other symptoms. A twin gestation (choice D) should have been seen on the 7-week ultrasound. Furthermore, a fundal height that is less than the gestational age would predict makes twins less likely. Uterine cancer (choice E) is very uncommon during pregnancy and would not be expected to present as decreased fundal height.
    --------------------------------------------------------------------------------
    23) A 33-year-old woman, gravida 3, para 3, comes to the physician for an annual examination. She has no complaints. Past medical history is significant for two episodes of Chlamydia and one episode of gonorrhea. Obstetric history is significant for three normal spontaneous vaginal deliveries with gestational diabetes during the last two pregnancies. She takes no medications. Family history is significant for paternal coronary artery disease. Physical examination is unremarkable. Which of the following interventions should this patient most likely have?
    A. Chest x-ray every 3 years
    B. Coronary angiography every 3 years
    C. Fasting glucose testing every 3 years
    D. Mammography every 3 years
    E. Pap testing every 3 years
    Explanation:
    The correct answer is
    C. Patients with a history of gestational diabetes have a high likelihood for eventually developing overt diabetes. These women should therefore be extensively counseled regarding the importance of diet and exercise. Along with counseling, testing is necessary to determine which patients actually do develop overt diabetes. Testing should be performed in the first few months following the delivery. This testing may be a 75-g, 2-hour, oral glucose tolerance test. Diabetes is diagnosed if the fasting glucose level exceeds 140 mg/dL, or two post-glucose measurements exceed 200 mg/dL. Patients should then undergo fasting glucose testing every 3 years. This patient, given her history of gestational diabetes, needs to have regular testing. Chest x-ray every 3 years (choice A) is not recommended as a screening test for this patient. Although the number of deaths from lung cancer surpasses that of breast cancer, and lung cancer is the leading cause of cancer death in women, routine chest x-ray is not used as a regular screening test. Coronary angiography every 3 years (choice B) would not be recommended for this patient. This is an invasive procedure that currently is not used as a regular screening test in the general population. Mammography every 3 years (choice D) would not be recommended for this patient. At 33 years of age, she does not yet require routine mammography. She should have a mammogram every 1-2 years starting at age 40, and then annually starting at age 50. Pap testing every 3 years (choice E) would not be recommended for this patient. Pap testing should be performed annually starting at age 18, or with the initiation of sexual intercourse. Some recommend that the interval can be increased at the physician's discretion in a low-risk patient with three normal Pap tests in a row. Others dispute this, arguing that annual Pap tests should be performed on all women. In any event, this patient, with her history of Chlamydia and gonorrhea, is not low risk and therefore needs annual Pap testing.
    --------------------------------------------------------------------------------
    24) A 40-year-old woman comes to the physician for an annual examination. She has no complaints. She has menses every 28-30 days that last for 3 days. She has no intermenstrual bleeding. She has asthma, for which she uses an occasional inhaler. She had a tubal ligation 10 years ago. She has no known drug allergies. Examination is unremarkable, including a normal pelvic examination. One of her friends was recently diagnosed with endometrial cancer, and the patient wants to know when and if she needs to be screened for this. Which of the following is the most appropriate response?
    A. Screening for endometrial cancer is not cost effective or warranted
    B. Screening is with endometrial biopsy and starts at age 40
    C. Screening is with endometrial biopsy and starts at age 50
    D. Screening is with ultrasound and starts at age 40
    E. Screening is with ultrasound and starts at age 50
    Explanation:
    The correct answer is
    A. Endometrial cancer is the most common gynecologic cancer in women older than 45. There are tens of thousands of new cases every year in the U.S., and thousands of deaths from it yearly. However, there is no effective screening test for endometrial cancer at this point. It is not cost-effective to screen asymptomatic women for endometrial cancer. Occasionally, a Pap test will detect abnormal endometrial cells, but it is not a proper screening tool for endometrial cancer. Patients with endometrial hyperplasia or cancer often present with irregular uterine bleeding. Therefore, patients with irregular uterine bleeding should be considered for endometrial biopsy or ultrasonic evaluation of the endometrial cavity. This strategy may be modified for young patients, in whom the risk of endometrial hyperplasia or cancer is limited. To state that screening is with endometrial biopsy and starts at age 40 (choice B) or age 50 (choice C) is incorrect. Endometrial biopsy can and should be used in certain circumstances. For example, a woman with postmenopausal bleeding should undergo the procedure. However, endometrial biopsy should not be

  2. #2
    Beaker's Avatar
    Beaker is offline Member 510 points
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    more to come....

    sorry guys. only half the questions fit on the post. you can download the word doc in the download area under usmle 2 ob/gyn. more to come....

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    Beaker's Avatar
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    instructions

    some people are having trouble, so here are some instructions. you need to go to the free downloads forum in valuemd, then open the announcement that says "click here for DOWNLOADS", then click "DOWNLOADS". That will take you to a full menu of download categories. for those ob questions, choose "OB/GYN" under step 2. If you still have questions, let me know.

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    Anonymous is offline Unregistered Guest
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    thanx

    thanks for the Q.. where can i find more Q to practice?
    thanx again

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    grey is offline Newbie 510 points
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    Mcq

    hi.
    i was looking for some MCQS
    if u can direct me to any place with a good library of them with explanation i will be thankfull

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    jagian is offline Newbie 510 points
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    Hi,
    I am not able to download. can anyone help?
    Thanks

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    nayabmom is offline Newbie 510 points
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    Mcq in ob/gy

    Thank you very much for the questions.Iwant more. can any one help? is this mrcog level or less?
    nayabmom

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    nayabmom is offline Newbie 510 points
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    Mcq in ob/gy

    Somebody help me....need to know where to find more mcqs.My exam is in 2 weeks time.
    I NEED HELP.

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    aida.alkhatib is offline Newbie 510 points
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    thank you............

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    XUSOM AdminHelp is offline Junior Member 511 points
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    Here is an interesting question...

    Prothrombin is a _______ globin produced by the ______.

    A. Alpha, Kidney
    B. Alpha, Liver
    C. Beta, Liver
    D. Beta, Kidney

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